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Form C: QUARTERLY REPORT

This report is used to update the Supplier Directory on the Medicare website
at http://www.medicare.gov/ with the products you plan to provide
during the NEXT quarter.

Please review your product information in the Supplier Directory before
completing this report. You must complete this report for every competitive
bidding area (CBA)/product category combination in your contract. Please refer
to your contract for a complete listing of your CBA/product category
combinations.

If a CBA/product category combination needs to be updated in the Supplier
Directory, you must complete information for ALL
HCPCS codes for that CBA/product category combination.

If some, but not all, CBA/product category combinations need to be updated
in the Supplier Directory, you must identify those that do NOT need to be
updated in section III of this form.

If all of your product information in the Supplier Directory for ALL
CBA/product category combinations is current, select “I have no updates for
any of my CBA/product category combinations” in section III.

Failure to submit a Form C for all CBA/product category combinations in your
contract may be considered a breach of contract and result in termination of
your contract.

IMPORTANT: Data entered into Form C does NOT save. After 60 minutes
of inactivity, Form C will time out and all data entered will be
lost.

You may enter all required information at one time and then select “View
Completed Form and Print,” OR you may choose to enter product information for
each single CBA/product category combination and then select “View Completed
Form and Print.” You must PRINT EACH FORM since this information is not saved
and cannot be retrieved after your browser closes. ALL forms must be signed by a
company official and sent (either by mail or fax) to the Competitive Bidding
Implementation Contractor (CBIC) and RECEIVED by the CBIC by the
deadline.
I. Business Information [*required]

Contract Supplier's Legal
Business Name*

Contract Number*

(Check your contract for
the contract number)

If Network, Primary
Supplier's Legal Business Name

Year*
2012

Quarter*
2nd

II. Update(s) to the Supplier Directory

Select a CBA/product category combination for the first product you are
reporting.

Select all additional CBAs in which the product will be made
available.

Select the HCPCS code for the product. If you do not see a particular
HCPCS code listed in the “HCPCS Code” dropdown box, you are not required to
report it.

Click “Model” and select the product’s model from the list of choices in
the dropdown box. If you do not see the product’s model, scroll to the bottom
of the list and select “Other – Not Listed.” Enter the model of the
product.
NOTE: Only select “Other – Not Listed" IF a particular
model does NOT appear in the list provided.

If you do not see the manufacturer and you selected “Other – Not Listed”
in the “Model” field, enter the manufacturer for the product. Click “Add
Product Information.”

The information you entered will appear in the table at the bottom of this
section. If you wish to remove an item from the table, click the corresponding
icon
for the item.

Repeat this process to add all the products you plan to make available in
the next quarter for the listed HCPCS codes and for ALL CBA/product category combinations for which you
were awarded a contract.

IMPORTANT: This update will delete all of your information currently
listed on the Supplier Directory and replace it with the products you enter on
Form C. Make sure you enter all of your products for every HCPCS code on Form C
even if you have no updates for one or more of the codes.

Competitive Bidding Area (CBA)/Product
Category

Select the HCPCS
Code.
(You must enter all products you
offer for every HCPCS code.)
HCPCS
Code

Related CBA(s) (Select all that
apply)
Hold CTRL key and click to select
multiples

Model

Model*

Manufacturer

Other Manufacturer*

Add Product Information

You have not provided
information for the following HCPCS in the following Competitive Bid Area(s).
You must provide this information before continuing:

List of Updates to the Supplier Directory

HCPCS Code

CBA/Product Category

Manufacturer

Model

III. No Updates to the Supplier Directory

If
the product information in the Supplier Directory is current for some but not
all of your CBA/product category combinations, select the CBA/product category
combination(s) that do NOT need to be updated.

CBA (Select all that
apply)
Hold CTRL key and click to select
multiples

Product Category (Select
all that apply)
Hold CTRL key and click to select
multiples

If the product information in the Supplier
Directory is current for ALL CBA/product category combinations, check
below.

I have no updates for any of my CBA/product
category combinations.

Add CBA/Product Category combination

List of CBA/Product Category combination(s) that do NOT need to be updated
in the Supplier Directory

CBA/Product
Category

View Completed Form and
Print

WARNING: You will not be able to make any changes to your information
once you proceed to the next page. Please review all information on this page
before you proceed to print. To review and make any changes to your information,
click "CANCEL." If you are ready to print, click "OK." If you use the browser to
go back after you click "OK", you will need to re-enter the information.

OK

CANCEL