Form CMS-10169 Subcontracting Disclosure

SAMPLE FORM: This form is being provided as a sample for contract suppliers to disclose information on their subcontracting arrangements to the Centers for Medicare &
Medicaid Services {CMS).

CONTRACT SUPPLIER'S DISCLOSURE OF SUBCONTRACTORS
Consistent with Article VIII of the Supplier Contract, provide the information below for each subcontractor{s). The authorized official must disclose to the Centers for M edicare
& Medicaid Services {CMS) information on each subcontracting relationship that the contract supplier has entered into to furnish items and services under its contract and
whether each subcontractor meets the accreditation requirements in 42 CFR

424.57,

1O

if applicable. This information must be provided wit hin

contract execution. For subcontracting arrangements entered into after contract award, the required disclosures must occur no later than

business days after final

1O business days after the date

the

contract supplier enters into a subcontracting arrangement. Please visit the Competitive Bidding Implementation Contractor {CBIC) website at www.dmecompetitivebid.com
for information regarding applicable accreditation requirements for subcontractors.

*· denotes required fields.

Legal Business Name*
Doing Business As Name*

D Same as Legal Busin ess Name
Provd
i e me address ofthe particular /ocacions that will perform che sutxoncraan
i gservice{s). Corporate headquarcers'
addresses are nor accepcable.

Address line 1 *
Address line 2
Oty*

B

State*
ZIP Code*
Phone Number*
Type of Subcontraaor Service(s)*

None selected

{Selea all that apply)

Does this apply to multiple

•

OVesONo

contracts?
Contraa Number*
Produa Category*
Product"
{Selea all that apply)
Competitive Bidding Area {CBA)*
{Selea all that apply)

v

None selected
None selected

•

•

I

Add Compet1t1on(s)

Review contract and competition information
Contract
Remove

Number

Product Category

Product

Add Subcontractor

Competitive Bidding Area

Edit

Cancel

Review Pending Changes
Type

Contract Number

Competitions

Edit

You must enter your Connexion userlD and click Sign and Submit. You can Print a copy of the submined form{s) for your records by clicking the Print Page. Please do

not mail or FAX any documents to the CBIC.

First Name

Phani

Last Name

Atluri

Connexion User ID

Pnnt Page

Back to Form(s) Summary

If you have any questions about this form, please contaa the CBIC customer service center at
Contract Supplier's Disclosure of Subcontractors Form {OMB No.

0938-1016 Exp. 9-2020)

Medicare Durable Medical Equipment, Prosthetics, Orthotics. and Supplies {DMEPOS)
COMPETITIVE BIDDING PROGRAM

877-577-5331.

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