Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Application for DMEPOS Competitve Bidding Program (Form A) Unchanged 1299 10389 0 Form and Instruction CMS-10169 Form A
Bidding Form (Form B) Unchanged 17944 215324 0 Form and Instruction CMS-10169 Form B _ Bidding Form
Change of Ownership (CHOW) - Purchaser Form Unchanged 111 111 0 Form and Instruction CMS-10169 Change of Ownership - Purchaser Form - 30-day notice
Change of Ownership (CHOW) Contract Supplier Notification Form Unchanged 92 46 0 Form and Instruction CMS-10169 Change of Ownership - Contract Supplier Notificaiton Form - 60-day Notice
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C) Modified 2494 831 0 Form and Instruction CMS-10169 Quarterly Report
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure Unchanged 390 160 0 Form and Instruction CMS-10169 Contract Suppliers Disclosure of Subcontractors
Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) Unchanged 14667 7333 0 Form and Instruction CMS-10169 Beneficiary Survey (English Language Version)
Form and Instruction CMS-10169 Beneficiary Survey (Spanish Language Version)
Total burden requested under this ICR: 36997 234194 0  
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