This form is no longer available for Round 2 and the national mail-order competition.
What is Form C
Form C is a quarterly report that contract suppliers are required under the terms of the contract to submit to the Centers for Medicare & Medicaid Services (CMS). The report collects the brands of competitively bid items contract suppliers plan to offer during the next quarter.
How Form C Information is Used
Information collected from the report is used by beneficiaries, customer service representatives at 1-800-MEDICARE, and referral agents in locating contract suppliers that furnish specific products. The information you provide on Form C about the products you make available is displayed on the Supplier Directory located on the Medicare website at www.medicare.gov/supplierdirectory/search.html.
Please check the Medicare Supplier Directory to review the "Brands Available" information listed for your company prior to completing Form C.
Disclaimer for Form C
You are responsible for ensuring that you enter only products that meet the requirements for each HCPCS code. Products listed in the drop down box for each HCPCS code have been verified by the Pricing, Data Analysis, and Coding (PDAC) contractor. If you would like to enter a product that is not listed in the drop down box but are not sure if the product meets the requirements for the HCPCS code, we urge you to contact the PDAC contractor for coding guidance via the contact form located at www.dmepdac.com/contact. As a reminder, failure to bill Medicare using the appropriate code may result in substantial penalties under the False Claims Act and exclusion from the Medicare Program.
How to Change Your Business Information
The business information listed for your company on the Supplier Directory (such as address, doing business as (DBA) name, telephone number and product categories) comes from your company's CMS-855S enrollment form on file with the National Supplier Clearinghouse (NSC) - NOT from the information you report on Form C.
- If you wish to update an existing address, DBA name, telephone number or product categories, please submit your changes to the NSC. You may find change-of-information guidelines on the NSC website at www.PalmettoGBA.com/NSC.
- If you wish to update an existing toll-free telephone number, please submit your changes to the Competitive Bidding Implementation Contractor (CBIC) by completing the Contract Supplier Change of Information Form on this website.
- If you wish to add a location to or remove a location from your contract, please complete the Contract Supplier Location Update Form, which is also available on this website.
When Form C is Due
The form is due no later than ten calendar days after each of the following dates: March 31; June 30; September 30; and December 31 throughout the entire contract period.
- Data entered into Form C does NOT save. You must PRINT EACH FORM since this information cannot be retrieved once you close your browser.
- After 60 minutes of inactivity, Form C will time out and all data entered will be lost.
- We cannot guarantee the availability of viewing on an unsupported browser. This website relies on current web standards to deliver better performance and greater security. You may view this site with an unsupported browser, but for predictable, reliable performance, we recommend installing one of the following supported browsers:
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If you have trouble upgrading, please contact your company's technical support group for assistance.
> Form C FAQs