Form B: Bidding Form

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CMS-10169)

Documents and Forms

Document Name Document Type
Form Form B Form B: Bidding Form Form and Instruction
Form B Bid Sheet 508_CMS-10169_Form_B.pdf Form and Instruction
Form B Certification Proposed Form B - Certification (No Changes).pdf Form and Instruction
Form B Create Bid Proposed Form B - Create Bid (No Changes).pdf Form and Instruction
Form B Manufacturer Proposed Form B - Manufacturer (No Changes).pdf Form and Instruction
Form B Manufacturer, Model Name, and Number Proposed Form B - Manufacturer, Model Name and Number (No Changes).pdf Form and Instruction
508 Compliant Form B - Crosswalk.pdf Form B: Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Form B: Bidding Form	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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form B	Bid Sheet	508_CMS-10169_Form_B.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	Form B	Certification	Proposed Form B - Certification (No Changes).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Form B	Create Bid	Proposed Form B - Create Bid (No Changes).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Form B	Manufacturer	Proposed Form B - Manufacturer (No Changes).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Form B	Manufacturer, Model Name, and Number	Proposed Form B - Manufacturer, Model Name and Number (No Changes).pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 350

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	37,833	20,333	17,500
Annual IC Time Burden (Hours)	42,834	-9,666	52,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Form B: Crosswalk	508 Compliant Form B - Crosswalk.pdf	07/10/2025

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