Form CMS-10169 Contract Suppliers Disclosure of Subcontractors

SAMPLE FORM: This form is being provided as a sample for contract suppliers to disclose information on their subcontracting arrangements to
the Centers for Medicare & Medicaid Services (CMS).

CONTRACT SUPPLIER’S DISCLOSURE OF
SUBCONTRACTORS
Consistent with Article VI of the Supplier Contract, provide the information below for each subcontractor(s). The authorized official must disclose
to the Centers for Medicare & Medicaid Services (CMS) information on each subcontracting relationship that the contract supplier has entered into
to furnish items and services under its contract and whether each subcontractor meets the accreditation requirements in 42 CFR 424.57, if
applicable. This information must be provided within 10 business days after final contract execution. For subcontracting arrangements entered into
after contract award, the required disclosures must occur no later than 10 business days after the date the contract supplier enters into a
subcontracting arrangement. Please visit the Competitive Bidding Implementation Contractor (CBIC) website at www.dmecompetitivebid.com for
information regarding applicable accreditation requirements for subcontractors.
* - denotes required fields

Provide the following information for each subcontractor:
Legal Business Name*

Doing Business As Name

Provide the address of the particular location that will
perform the subcontracting service(s).
Corporate headquarters' addresses are not acceptable.
Address Line 1*
City*

Same as Legal Business Name
Address Line 2
State*



ZIP Code*
-

Phone Number:*
Type of Subcontractor Service (Select all that apply)*
Hold CTRL key and click to select multiples
Delivery
Instruction
Purchase of Inventory
Repair of Rented Equipment

Does this apply to multiple contracts?
Contract Number*

Yes

No

(Check your contract(s) for the contract number.)

 -

Product Category (PC)*



Competitive Bidding Area (CBA) (Select all that apply)*
Hold CTRL key and click to select multiples

Add PC/CBAs

Review contract and competition information
Delete Contract Number

Product Category

Competitive Bidding Area

Edit

Add Subcontractor
Cancel

Review Pending Change
Type

Contract Number

Competitions

Edit
Review & Print

SAMPLE FORM: This form is being provided as a sample for contract suppliers to disclose information on their subcontracting arrangements to
the Centers for Medicare & Medicaid Services (CMS).

CONTRACT SUPPLIER’S DISCLOSURE OF
SUBCONTRACTORS
Consistent with Article VI of the Supplier Contract, provide the information below for each subcontractor(s). The authorized official must disclose
to the Centers for Medicare & Medicaid Services (CMS) information on each subcontracting relationship that the contract supplier has entered into
to furnish items and services under its contract and whether each subcontractor meets the accreditation requirements in 42 CFR 424.57, if
applicable. This information must be provided within 10 business days after final contract execution. For subcontracting arrangements entered into
after contract award, the required disclosures must occur no later than 10 business days after the date the contract supplier enters into a
subcontracting arrangement. Please visit the Competitive Bidding Implementation Contractor (CBIC) website at www.dmecompetitivebid.com for
information regarding applicable accreditation requirements for subcontractors.
* - denotes required fields

Provide the following information for each subcontractor:
Legal Business Name*

Doing Business As Name

Provide the address of the particular location that will
perform the subcontracting service(s).
Corporate headquarters' addresses are not acceptable.
Address Line 1*
City*

Same as Legal Business Name
Address Line 2
State*



ZIP Code*
-

Phone Number:*
Type of Subcontractor Service (Select all that apply)*
Hold CTRL key and click to select multiples
Delivery
Instruction
Purchase of Inventory
Repair of Rented Equipment

Does this apply to multiple contracts?
Contract Number*

Yes

No

(Check your contract(s) for the contract number.)

 -

Product Category (PC)*



Competitive Bidding Area (CBA) (Select all that apply)*
Hold CTRL key and click to select multiples

Add PC/CBAs

Review contract and competition information
Delete Contract Number

Product Category

Competitive Bidding Area

Edit

Add Subcontractor
Cancel

Review Pending Change
Type

Contract Number

Competitions

Edit
Review & Print

If you have any questions about this form, please contact the CBIC customer service center at 877-577-5331.
Contract Supplier’s Disclosure of Subcontractors Form (OMB No. 0938-1016)
Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

COMPETITIVE BIDDING PROGRAM

https://www.dmecompetitivebid.com/secure/cbicsecure.nsf/SubConDisc

3/26/2014