FORM C Semi Annual Report Screen Shot 2

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

Form C: Semi-Annual Report
January 1, 2017 May 31, 2017 / 23-4666516 I Nebulizers and Re/acedSupplies
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You must provide product information for select items in the product category(s) on your contract. The item is identified on Form C by the Healthcare Common Procedure
Coding system (HCPCSJ code.
1. Choose a manufacturer,
2. Use the Select buttons to select model(s) and/or model number(s) for the items that you currently furnish or will furnish. You may use the Select All button to select all
models listed for the manufacturer.
3. Click on Choose CBA next to the selected model to choose the CBA(s) where the model will be furnished. If mult iple models are selected that will be furnished in the
same CBA(s), click on Select CBAs to choose the CBA(s). then click on the Apply to Selected Models button.
4. Repeat steps 1-3 to add models for other manufacturers.
5. If the manufacturer or model is not displayed, click on the Add Manufacturer/Model button and enter the product information (manufacturer, model, and model
number) and choose the CBA(s) for the model. To add another manufacturer or model, click on the Add More button. To remove a manufacturer or model, click on the
Remove button.
6. Click on Continue to the Next HCPCS Code to enter information for another item. You must select at least one model for a manufacturer before you can proceed to the
next HCPCS code.
7. Once you have entered product information for each listed HCPCS code, sign the form and you will be taken to the Form(s) Summary page.
8. To enter product information for another product category. go co the Forms ca b at the cop of the page and select Form C.
9. Repeat the steps above co enter produce information for all product categories on your contract.
10. If you have other contract numbers displayed on Form C, you muse complete these seeps for each DMEPOS Competitive Bidding Program contract.

Form C Legend
HCPCS code E0570 (1 of 1 HCPCS codes for this product category)
Nebulizer, with compressor

Select a Manufacturer/Model
ACCESS POINT MEDICAL LLC
AG INDUSTRIES
AMERICAN BANTEX CORP
APEX MEDICAL USA CORP
BESTMED LLC (POLY GREEN CO LTD)
SEURER GMBH I SEURER NORTH AMERICA LP
BRIGGS HEALTHCARE
CYPRESS MEDICAL PRODUCTS
DALTON MEDICAL CORP
DEVILBISS HEALTHCARE LLC
DR K HEALTHCARE PRODUCTS INC

ReviewNeeded

DRIVE MEDICAL

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1 selected

DYNAREX CORP
GF HEAL TH PRODUCTS INC
HEALTHDYNE
HOME AIDE DIAGNOSTICS INC
INVACARE CORP
MABIS HEALTHCARE INC
MADA MEDICAL
MEDEL SPA

...

MEDINVENT LLC
MEDLINE INDUSTRIES INC
MEDQUIP INC
MERITS HEALTH PRODUCTS INC
NIDEK MEDICAL
OMRON HEALTHCARE INC
PARI RESPIRATORY EQUIPMENT INC

...

PHILIPS RESPIRONICS
PRECISION MEDICAL INC
PROBASICS BY PMI
RESPIRONICS INC

...

ROSCOE MEDICAL INC
SALTER LABS

ReviewNeeded

SAMSUNG AMERICA INC

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1 selected

Review Needed

SUNRISE MEDICAL (US) LLC

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1 selected

TECHNOLOGY & HEALTH LLC

ReviewNeeded

THE LUMISCOPE COMPANY INC

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1 selected

VALUE PROVIDERS LLC (OBA VPI AND KX MEDICAL)

...

ReviewNeeded

Add Manufacturer/Model

Change Product Category

Continue to eS1gnature