SAMPLE FORM: This form is being provided as a
sample for contract suppliers to disclose information on their subcontracting
arrangements to the Centers for Medicare & Medicaid Services (CMS).

CONTRACT SUPPLIER’S DISCLOSURE OF SUBCONTRACTORS

Consistent with Article VI of the Supplier Contract, provide the information
below for each subcontractor(s). The Authorized Official must disclose to the
Centers for Medicare & Medicaid Services (CMS) information on each
subcontracting relationship that the contract supplier has entered into to
furnish items and services under its contract and whether each subcontractor
meets the accreditation requirements in 42 CFR 424.57, if applicable. This
information must be provided within 10 business days after final contract
execution. For subcontracting arrangements entered into after contract award,
the required disclosures must occur no later than 10 business days after the
date the contract supplier enters into a subcontracting arrangement. Please
visit the Competitive Bidding Implementation Contractor (CBIC) website at www.dmecompetitivebid.com for information regarding
applicable accreditation requirements for subcontractors.

Please provide the following information for the contract supplier:

Provide the following information for the contract
supplier:

* - denotes required
fields

Bidder Number*

Contract
Number*

PTAN*

Provide the following information for each
subcontractor:

* - denotes
required fields

Legal Business
Name*

Doing Business As
Name

Provide the address of the particular location that will perform
the subcontracting service(s).
Corporate headquarters' addresses are
not acceptable.

Address Line 1*

Address Line
2

City*

State*

ZIP Code*
-

Phone Number:*
Area Code- Phone
Prefix- Phone
Line

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

Type of Subcontractor Service
(Select all that apply)*
Hold CTRL key and click to select
multiples

Meets Accreditation Requirements, if
applicable*
YesNo

*IMPORTANT: If the subcontractor is
required to be accredited, you must submit a copy of the accreditation
certificate to the CBIC.

Add Subcontractor

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If you have any questions
about this form, please contact the CBIC customer service center at
877-577-5331.

Contract Supplier’s Disclosure of
Subcontractors Form
Medicare Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS)
COMPETITIVE
BIDDING PROGRAM – ROUND 1 REBID