Change of Ownership

Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program – Contracting Forms (CMS-10744)

Documents and Forms

Document Name Document Type
Form CMS-10744.Change o Change of Ownership Form and Instruction
CMS-10744.Change o CMS-10744.Change of Ownership Form (30-day notice) CMS-10744.Change of Ownership Form (30-day notice).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Change of Ownership	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.422(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10744.Change of Ownership Form (30-day notice)	CMS-10744.Change of Ownership Form (30-day notice)	CMS-10744.Change of Ownership Form (30-day notice).pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4	4
Annual IC Time Burden (Hours)	7	7
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.