Information Collection

Form A: Application for DMEPOS Competitve Bidding Program

IC 232396 under ICR 202512-0938-005 · OMB 0938-1016.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form A Form A: Application for DMEPOS Competitve Bidding Program Form A: Application for DMEPOS Competitve Bidding Program	Form and Instruction
Form Form A Business Organization Form A: Application for DMEPOS Competitve Bidding Program	Form and Instruction
Form A Form A: Application for DMEPOS Competitve Bidding Progra Form A - Business Organization Information_Attestation.jpg	Form and Instruction
Form A Business Organization Proposed Form A - Business Organization.pdf	Form and Instruction
Form A Crosswalk_05202025.xlsx Crosswalk: Form A	IC Document

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form A				Yes	Yes	Fillable Fileable
Form and Instruction	Form A				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 350

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	1,550	-2,625	4,175
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Form A		06/04/2026

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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