Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Application for DMEPOS Competitve Bidding Program (Form A) Removed 0 0 0 Form and Instruction CMS-10169 Form A
Bidding Form (Form B) Modified 17500 52500 0 Form and Instruction CMS-10169 Form B _ Bidding Form
Change of Ownership (CHOW) - Purchaser Form Removed 0 0 0 Form and Instruction CMS-10169 Change of Ownership - Purchaser Form - 30-day notice
Change of Ownership (CHOW) Contract Supplier Notification Form Removed 0 0 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) Removed 0 0 0 Form and Instruction CMS-10169 Quarterly Report
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure Removed 0 0 0 Form and Instruction CMS-10169 Contract Suppliers Disclosure of Subcontractors
Form A: Application for DMEPOS Competitve Bidding Program New 500 4175 0 Form and Instruction CMS-10169 Form A: Application for DMEPOS Competitve Bidding Program
Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D) Removed 0 0 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: 18000 56675 0  
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