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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10169 Change of Ownership (CHOW) Forms-60-day & 30-day notices Form and Instruction
CMS-10169 CHOW 30-day Notice (Change of Ownership Form) Connexion - CHOW 30.pdf Form and Instruction
CMS-10169 CHOW 30-day Notice (Change of Ownership Form) Connexion - CHOW 60 day.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Change of Ownership (CHOW) Forms-60-day & 30-day notices	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 92	Number of Respondents for Small Entity: 64

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	92	0	92
Annual IC Time Burden (Hours)	169	123	46
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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