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Form A: Application for DMEPOS Competitve Bidding Program
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program
OMB: 0938-1016
IC ID: 232396
OMB.report
HHS/CMS
OMB 0938-1016
ICR 201807-0938-009
IC 232396
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1016 can be found here:
2018-12-06 - Reinstatement with change of a previously approved collection
Documents and Forms
Document Name
Document Type
Form CMS-10169
Form A: Application for DMEPOS Competitve Bidding Program
Form and Instruction
CMS-10169 Form A: Application for DMEPOS Competitve Bidding Progra
CMS-10169_Next_Round_Form_A.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Form A: Application for DMEPOS Competitve Bidding Program
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 414.410
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
Form A: Application for DMEPOS Competitve Bidding Program
CMS-10169_Next_Round_Form_A.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
500
Number of Respondents for Small Entity:
350
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
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
500
0
500
0
0
0
Annual IC Time Burden (Hours)
4,175
0
4,175
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
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.