FORM C Semi Annual Report Screen Shot 1

(OMB No. 0938-1016 Exp. 9-2020)

Form C: Semi-Annual Report
What is Form C? 0
How is Form C Information Used? 0
When is Form C Due? 0
Disclaimer for Form C
You are responsible for ensuring that you enter only products that meet the requirements for each Healthcare Common Procedure Coding system (HCPCS) code. Products
listed for each HCPCS code have been verified by the Pricing. Data Analysis, and Coding (PDAC) contractor. If you would like to enter a product that is not listed in the drop
down box. but are not sure if the product meets the requirements for the HCPCS code, we urge you to contact the PDAC contractor for coding guidance via the contact form
located at www.dmepdac.com/contact. As a reminder, failure to bill Medicare using the appropriate code may result in substantial penalties under the False Cl aims Act and
exclusion from the Medicare Program.

Failure to submit a Form C for all competitive bidding area (CBA)/product category combinations in your contract may be considered a breach of contract and
result in termination of your contract.
IMPORTANT: Data entered into Form e, which has not been signed and submitted, will not save. For securitypurposes, Form C will time out after 30 minutes of
inactivity and all data entered will be lost.

Select a Product Category
*·

denotes required fields.

Reporting Period
Reporting Deadline

January 1, 2017 - May31, 2017
January 17, 2017

Contract Number*
Product Category*

Select Contract