Information Collection

Application for DMEPOS Competitve Bidding Program (Form A)

IC 212256 under ICR 201701-0938-004 · OMB 0938-1016.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1016 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FORM A Application for DMEPOS Competitve Bidding Program (Form A)	Form and Instruction
FORM A Multi Location Bidder Form A - Multi Location Bidder-508.pdf	Form and Instruction
FORM A Network Bidder Form A - Network Bidder-508.pdf	Form and Instruction
FORM A Single Location Bidder Form A - Single Location Bidder-508.pdf	Form and Instruction
FORM A Round 1 -2019 R2019 Form A -508.pdf	Form and Instruction
508_DBidS Form A Screenshot 3.pdf Form A Screenshot 3	IC Document
508_DBidS Form A Screenshot 1.pdf Form A Screenshot 1	IC Document
508_DBidS Form A Screenshot 2.pdf Form A Screenshot 2	IC Document
508_DBidS Form A Screenshot 4.pdf Form A Screenshot 4	IC Document
508_DBidS Form A Screenshot 5.pdf Form A Screenshot 5	IC Document
508_DBidS Form A Screenshot 6.pdf Form A Screenshot 6	IC Document
508_DBidS Form A Screenshot 7.pdf Form A Screenshot 7	IC Document
508_DBidS Form A Screenshot 8.pdf Form A Screenshot 8	IC Document
508_DBidS Form A Screenshot 9.pdf Form A Screenshot 9	IC Document

IC Title:

Application for DMEPOS Competitve Bidding Program (Form A)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 414.410

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FORM A	Multi Location Bidder	Form A - Multi Location Bidder-508.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	FORM A	Network Bidder	Form A - Network Bidder-508.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	FORM A	Single Location Bidder	Form A - Single Location Bidder-508.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	FORM A	Round 1 -2019	R2019 Form A -508.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	500	-799	1,299
Annual IC Time Burden (Hours)	4,175	-6,214	10,389
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.