Information Collection Request

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

ICR 201807-0938-009 · OMB 0938-1016 · Historical Inactive

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10169 Form A: Application for DMEPOS Competitve Bidding Program Form and Instruction New Available
Form CMS-10169 Form B _ Bidding Form Form and Instruction Modified Available
Form CMS-10169 Form A Form and Instruction Removed Available
Form CMS-10169 Change of Ownership - Purchaser Form - 30-day notice Form and Instruction Removed Available
Form CMS-10169 Change of Ownership - Contract Supplier Notificaiton Form - 60-day Notice Form and Instruction Removed Available
Form CMS-10169 Contract Suppliers Disclosure of Subcontractors Form and Instruction Removed Available
Form CMS-10169 Beneficiary Survey (Spanish Language Version) Form and Instruction Removed Available
Form CMS-10169 Beneficiary Survey (English Language Version) Form and Instruction Removed Available
Form CMS-10169 Quarterly Report Form and Instruction Removed Available
CMS-10169_Next_Round_Crosswalk_Form_B.pdf Supplementary Document Uploaded 2018-07-25 Available
CMS-10169_Supporting_Statement_Part_A.docx Supporting Statement A Uploaded 2018-07-25 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
232396 Form A: Application for DMEPOS Competitve Bidding Program Form and Instruction NewForm A: Application for DMEPOS Competitve Bidding Program
212257 Bidding Form (Form B) Form and Instruction ModifiedForm B _ Bidding Form
212256 Application for DMEPOS Competitve Bidding Program (Form A) Form and Instruction RemovedForm A
206873 Change of Ownership (CHOW) - Purchaser Form Form and Instruction RemovedChange of Ownership - Purchaser Form - 30-day notice
206872 Change of Ownership (CHOW) Contract Supplier Notification Form Form and Instruction RemovedChange of Ownership - Contract Supplier Notificaiton Form - 60-day Notice
203541 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure Form and Instruction RemovedContract Suppliers Disclosure of Subcontractors
203540 Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) Form and Instruction RemovedBeneficiary Survey (Spanish Language Version)
203540 Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) Form and Instruction RemovedBeneficiary Survey (English Language Version)
203539 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C) Form and Instruction RemovedQuarterly Report

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
36 Months From Approved 05/07/2018
0 0 19,053
0 0 18,870
0 0 0





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IC Title Form No. Form Name
Application for DMEPOS Competitve Bidding Program (Form A) CMS-10169
Bidding Form (Form B) CMS-10169
Change of Ownership (CHOW) - Purchaser Form CMS-10169
Change of Ownership (CHOW) Contract Supplier Notification Form CMS-10169
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C) CMS-10169
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure CMS-10169
Form A: Application for DMEPOS Competitve Bidding Program CMS-10169
Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) CMS-10169, CMS-10169 ,  



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