[Federal Register: April 18, 2003 (Volume 68, Number 75)]
[Notices]
[Page 19210-19211]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr18ap03-55]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare and Medicaid Services
[Document Identifier: CMS-R-242, CMS-1763, CMS-4040-SP, CMS-10069, CMS-
R-52, CMS-R-30]
Agency Information Collection Activities: Submission for OMB
Review; Comment Request
AGENCY: Centers for Medicare and Medicaid Services, HHS.
In compliance with the requirement of section 3506(c)(2)(A) of the
Paperwork Reduction Act of 1995, the Centers for Medicare and Medicaid
Services (CMS) (formerly known as the Health Care Financing
Administration (HCFA)), Department of Health and Human Services, is
publishing the following summary of proposed collections for public
comment. Interested persons are invited to send comments regarding this
burden estimate or any other aspect of this collection of information,
including any of the following subjects: (1) The necessity and utility
of the proposed information collection for the proper performance of
the agency's functions; (2) the accuracy of the estimated burden; (3)
ways to enhance the quality, utility, and clarity of the information to
be collected; and (4) the use of automated collection techniques or
other forms of information technology to minimize the information
collection burden.
1. Type of Information Collection Request: Extension of a currently
approved collection.
Title of Information Collection: Refinement of RHC Certification
and QAPI and Supporting Regulations in 42 CFR 491.8 and 491.11.
Form No.: CMS-R-242 (OMB 0938-0792).
Use: This collection contains information collection requirements
concerning requests for additional waivers of staffing requirements and
documentation of quality assessment and performance improvement
programs.
Frequency: Annually.
Affected Public: Business or other for-profit.
Number of Respondents: 3,528.
Total Annual Responses: 3,573.
Total Annual Hours: 3,663.
2. Type of Information Collection Request: Extension of a currently
approved collection.
Title of Information Collection: Request for Termination of
Premium+Hospital and/or Supplementary Medical Insurance.
Form No.: CMS-1763 (OMB 0938-0025).
Use: The CMS-1763 is used by beneficiaries to request voluntary
termination from Premium Hospital Insurance (premium-HI) and/or
Supplementary Medicare Insurance (SMI).
Frequency: One time only.
Affected Public: Individuals or Households, Federal Government,
State, local, and tribal government.
Number of Respondents: 14,000.
Total Annual Responses: 14,000.
Total Annual Hours: 5,833.
3. Type of Information Collection Request: Extension of a currently
approved collection.
Title of Information Collection: Request for Enrollment in
Supplemental Medicare Insurance and Supporting Regulations in 42 CFR
407.10 and 401.11.
Form No.: CMS-4040 and 4040-SP (OMB 0938-0245).
Use: The CMS 4040 is used to establish entitlement to Supplemental
Medical Insurance (Part B) by beneficiaries not eligible under Part A
of the Title XVIII or Title II of the Social Security Act. The CMS-
4040SP is also included in this renewal.
Frequency: One time only.
Affected Public: Individuals or Households, Federal Government,
State, local, and tribal government.
Number of Respondents: 10,000.
Total Annual Responses: 10,000.
Total Annual Hours: 2,500.
4. Type of Information Collection Request: Extension of a currently
approved collection.
Title of Information Collection: Medicare Waiver Demonstration
Application.
Form No.: CMS-10069 (OMB 0938-0880).
Use: The Medicare Waiver Demonstration Application will be used to
collect standard information needed to implement Congressionally
mandated
[[Page 19211]]
and administration high priority demonstrations. The application will
be used to gather information about the characteristics of the
applicant's organization, benefits, and services they propose to offer,
success in operating the model, and evidence that the model is likely
to be successful in the Medicare program. The standard application will
be used for all waiver demonstrations and will reduce the burden on
applicants, provide for consistent and timely information collections
across demonstration, and provide a user-friendly format for
respondents.
Frequency: On Occasion.
Affected Public: Business or other for-profit and Not-for-profit
institutions.
Number of Respondents: 75.
Total Annual Responses: 75.
Total Annual Hours: 1600.
5. Type of Information Collection Request: Extension of a currently
approved collection.
Title of Information Collection: Conditions of Coverage of
Suppliers of End Stage Renal Disease (ESRD).
Form No.: CMS-R-52 (OMB 0938-0386).
Use: This package is needed to encourage proper distribution and
effective utilization of ESRD treatment sources while maintaining and
improving the efficient delivery of care by physicians and dialysis
facilities.
Frequency: Annually.
Affected Public: Business or other for-profit and Federal
Government.
Number of Respondents: 4,297.
Total Annual Responses: 4,297.
Total Annual Hours: 148,785.
6. Type of Information Collection Request: Revision of a currently
approved collection.
Title of Information Collection: Information Collection
Requirements in the Hospice Conditions Coverage. The following
regulations are affected: 42 CFR 418.22; 418.24; 418.28; 418.56(b),
(e)(1), (e)(3); 418.58; 418.70(e); 418.83; 418.96(b); and 418.100(b).
Form No.: CMS-R-30 (OMB 0938-0302).
Use: Establishes standards for hospices that wish to participate in
the Medicare program. The regulations establish standards for
eligibility, reimbursement standards and procedure, and delineate
conditions that hospices must meet to be approved for participation in
Medicare.
Frequency: On occasion.
Affected Public: Business or other for-profit.
Number of Respondents: 2,316.
Total Annual Responses: 2,316.
Total Annual Hours: 5,981,427.
To obtain copies of the supporting statement and any related forms
for the proposed paperwork collections referenced above, access CMS Web
site address at http://cms.hhs.gov/regulations/pra/default.asp, or e-
mail your request, including your address, phone number, OMB number,
and CMS document identifier, to Paperwork@hcfa.gov, or call the Reports
Clearance Office on (410) 786-1326. Written comments and
recommendations for the proposed information collections must be mailed
within 30 days of this notice directly to the OMB desk officer: OMB
Human Resources and Housing Branch, Attention: Brenda Aguilar, New
Executive Office Building, Room 10235, Washington, DC 20503.
Dated: April 10, 2003.
Dawn Willinghan,
Acting Paperwork Reduction Act Team Leader, CMS Reports Clearance
Officer, Office of Strategic Operations and Regulatory Affairs,
Division of Regulations Development and Issuances.
[FR Doc. 03-9548 Filed 4-17-03; 8:45 am]
BILLING CODE 4120-03-P