CMS-10169_Next_Round_Crosswalk_Form_B

Current Placement
Section 2

Title
Expansion Plans

Current Language
Can you increase your current capacity for this product category in this CBA?
 Yes No

Revised Language
FORM B
This Section is being removed.

Revised
Placement

Reason for Change

Not
Applicable

This section is being
removed from Bidding
Form B to reduce the
burden for bidders by
streamlining the
bidding process.

This Section is being removed.

Not
Applicable

This section is being
removed from Bidding
Form B to reduce the
burden for bidders by
streamlining the
bidding process.

This Section is being removed.

Not
Applicable

This section is being
removed from Bidding
Form B to reduce the
burden for bidders by
streamlining the
bidding process.

Do you plan to use subcontractors to assist you in carrying out the terms of
your contract? Yes No

This Section is being removed.

Not
Applicable

This section is being
removed from Bidding
Form B to reduce the
burden for bidders by
streamlining the
bidding process.

Select one or more of the following functions that the subcontractor(s)
will perform:
 De live ry o f Me d ic a re -c o ve re d ite m o n ly
 S e t-u p a n d /o r in s tru c tio n o n u s e o f Me d ic a re -c o ve re d ite m
 Re p a ir o f re n te d e q u ip m e n t o n ly
 P u rc h a s e o f in ve n to ry

This Section is being removed.

Not
Applicable

This section is being
removed from Bidding
Form B to reduce the
burden for bidders by
streamlining the
bidding process.

If you answer “Yes” to this question, describe your current structure and
expansion plan in the space provided. If a particular item
does not apply, please leave the field blank but ensure you provide an
explanation in all applicable fields. If additional space is
needed, you may submit documentation along with the required hardcopy
documents.
Staff (manpower)
Current:
Expansion Plan:
Financing (funding levels):
Current:
Expansion Plan:
Facilities (square footage, facility):
Current:
Expansion Plan:
Inventory Control (method of tracking inventory):
Current:
Expansion Plan:
Distribution Methods (vehicles, mail order):
Current:
Expansion Plan:

Section 3

Subcontractor
Information

Additional Information:
Current:
Expansion Plan:
Please note that subcontracting arrangements must be in compliance with the
Supplier Standards and subcontractor(s) can only perform services allowed
under these standards. If a subcontractor is providing the service to set-up
and/or provide instruction on the use of Medicare-covered item(s), the
subcontractor must be accredited by a CMS approved accreditation
organization.