CBIC - Round 2

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Forms

These forms are no longer available for Round 2 and the national mail-order competition.

Change of Ownership - Contract Supplier Notification Form Per Article V of the DMEPOS competitive bidding contract and §414.422(d)(1), a contract supplier is obligated to notify CMS at least 60 calendar days before the anticipated date of a change of ownership (CHOW). Contract suppliers should provide the information contained on this form. Failure to notify CMS may result in a breach of contract. Please refer to the CHOW fact sheet for more detailed information and instructions.	06/30/2016
Change of Ownership - Purchaser Form Purchasers of contract suppliers may request the transfer of a contract as part of a change of ownership transaction. A Purchaser should provide all information on this form and the required documentation outlined in the Change of Ownership (CHOW) fact sheet at least 30 calendar days before the effective date of the CHOW.	06/30/2016
Contract Supplier Change of Information Form Contract suppliers may request to change an authorized official to another authorized official on their enrollment file in the Provider Enrollment, Chain, and Ownership System (PECOS) and with the National Supplier Clearinghouse, change an e-mail address or phone number for an AO or BAO, or add/update a toll-free number for the Supplier Directory on the Medicare website.	06/30/2016
Contract Supplier Location Update Form Contract suppliers may request that locations be added to or removed from their contracts. Additions or removals may be requested at any time. All requests are subject to approval by the Centers for Medicare & Medicaid Services (CMS) and will be processed as quickly as possible after final contract execution.	06/30/2016
Form C Instructions to complete the quarterly report updating product information posted on the Medicare Supplier Directory.	06/30/2016
Subcontractor Disclosure Form The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires contract suppliers to disclose to CMS information regarding their subcontracting relationships.	06/30/2016

last updated on 06/30/2016

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