Form CMS-10744 Subcontracting Disclosure

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 VIII 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 is accredited as required by section 1847(b)(3)(C) of the
Social Security Act, if applicable. This information must be provided no later than10
business days after the Contract becomes effective, or for subcontracting arrangements
entered into after the Contract becomes effective, 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 about subcontracting and applicable accreditation requirements for
subcontractors.
Please provide the following information for the contract supplier:
Contract Supplier Information:
Contract Number

PTAN

Please provide the following information for each subcontractor:
Information for Each Subcontractor:
Legal Business Name

Doing Business As Name

Address

City

Phone

CBA

Type of Subcontractor Service
Purchase of Inventory
Delivery & Instruction
Maintenance and Repair of Rented Equipment

*Meets Accreditation Requirements, if Applicable
Yes
No

State

Zip Code

*IMPORTANT: If the subcontractor is required to be accredited, you must submit a copy of the accreditation
certificate to the CBIC.

Information for Each Subcontractor:
Legal Business Name

Doing Business As Name

Address

City

Phone

CBA

Type of Subcontractor Service
Purchase of Inventory
Delivery & Instruction
Maintenance and Repair of Rented Equipment

*Meets Accreditation Requirements, if Applicable
Yes
No

State

Zip Code

*IMPORTANT: If the subcontractor is required to be accredited, you must submit a copy of the accreditation
certificate to the CBIC.

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).

Information for Each Subcontractor:
Legal Business Name

Doing Business As Name

Address

City

Phone

CBA

Type of Subcontractor Service
Purchase of Inventory
Delivery & Instruction
Maintenance and Repair of Rented Equipment

*Meets Accreditation Requirements, if Applicable
Yes
No

State

Zip Code

*IMPORTANT: If the subcontractor is required to be accredited, you must submit a copy of the accreditation
certificate to the CBIC.

Information for Each Subcontractor:
Legal Business Name

Doing Business As Name

Address

City

Phone

CBA

Type of Subcontractor Service
Purchase of Inventory
Delivery & Instruction
Maintenance and Repair of Rented Equipment

*Meets Accreditation Requirements, if Applicable
Yes
No

State

Zip Code

*IMPORTANT: If the subcontractor is required to be accredited, you must submit a copy of the accreditation
certificate to the CBIC.

By my signature, as the authorized official named below, I certify that the contract
supplier’s subcontractor disclosure information is complete and accurate for the
DMEPOS Competitive Bidding Program.
Authorized Official Supplier Name (First, Middle, Last, Jr., Sr., etc.)
PRINT

Signature

Title/Position

Date

You may use this sample form or a similar form that provides the same information to
disclose your subcontracting arrangements. Please complete a Contract Supplier’s
Disclosure of Subcontractors form and submit to the CBIC by one of two methods along
with the subcontractor’s accreditation certificate, if applicable:
Fax: 803-264-6228
E-Mail: [email protected]
If you have any questions about this form, please call the CBIC customer service center
at 877-577-5331 between 9 a.m. and 5:30 p.m. prevailing Eastern Time, Monday
through Friday.