Information Collection

Form A: Application for DMEPOS Competitve Bidding Program

IC 232396 under ICR 201812-0938-004 · OMB 0938-1016.

⚠️ Notice: This information collection may be referencing outdated material.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 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: Modified

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

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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	4,175	4,175
Annual IC Cost Burden (Dollars)	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.