This form is no longer available for Round 1 Recompete.
The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires contract suppliers to disclose to the Centers for Medicare & Medicaid Services (CMS) information regarding their subcontracting relationships. This information must be provided within 10 business days after final contract execution. For subcontracting arrangements entered into after contract award, contract suppliers must provide the required information no later than 10 business days after the date the contract supplier enters into a subcontracting arrangement. The required form to notify CMS of subcontracting relationships is provided below.
The Supplier Standards limit Medicare-enrolled suppliers’ subcontracting arrangements to:
1) purchase of inventory;
2) delivery and instruction on the use of Medicare-covered items; and
3) maintenance and repair of rented equipment.
Services such as intake and assessment, coordination of care with the physician, submitting claims on behalf of the beneficiary, ownership and responsibility of equipment furnished to the beneficiary, and ensuring product safety must be provided by the contract supplier.