Change of Ownership (CHOW) Forms-60-day & 30-day notices

Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

OMB: 0938-1016

IC ID: 206872

Information Collection (IC) Details

View Information Collection (IC)

Change of Ownership (CHOW) Forms-60-day & 30-day notices
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10169 CHOW 30-day Notice (Change of Ownership Form) Connexion - CHOW 30.pdf Yes Yes Fillable Fileable Signable
Form and Instruction CMS-10169 CHOW 30-day Notice (Change of Ownership Form) Connexion - CHOW 60 day.pdf Yes Yes Fillable Fileable Signable

Health Health Care Services

 

92 64
   
Private Sector Businesses or other for-profits
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 92 0 0 0 0 92
Annual IC Time Burden (Hours) 169 0 0 123 0 46
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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