[Federal Register: January 30, 2004 (Volume 69, Number 20)]
[Notices]
[Page 4520]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr30ja04-67]
[[Page 4520]]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare and Medicaid Services
[Document Identifier: CMS-1561; CMS-367, 367a, and 367c; CMS-417; CMS-
10105 and CMS-10106]
Agency Information Collection Activities: Proposed Collection;
Comment Request
AGENCY: Centers for Medicare and Medicaid Services.
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: Health Insurance
Benefit Agreement and Supporting Regulations in 42 CFR Section 489;
Form No.: CMS-1561 (OMB 0938-0832); Use: Applicants to the
Medicare program are required to agree to provide services in
accordance with Federal requirements. The CMS-1561 is essential for CMS
to ensure that applicants are in compliance with the requirements.
Applicants will be required to sign the completed form and provide
operational information to CMS to assure that they continue to meet the
requirements after approval; Frequency: Other: as needed; Affected
Public: Business or other for-profit, Not-for-profit institutions, and
State, Local or Tribal Government; Number of Respondents: 3,000; Total
Annual Responses: 3,000; Total Annual Hours: 150.
2. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Medicaid Drug
Rebate Program--Manufacturers; Form No.: 0938-0578 (CMS-367, 367a, and
367c); Use: Section 1927 requires drug manufacturers to enter into and
have in effect a rebate agreement with the Federal Government for
States to receive funding for drugs dispensed to Medicaid recipients;
Frequency: Quarterly; Affected Public: Business or other for-profit;
Number of Respondents: 551; Total Annual Responses: 2,204; Total Annual
Hours: 54,660.
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Hospice Request
for Certification in the Medicare Program; Form No.: CMS-417
(OMB 0938-0313); Use: The Hospice Request for Certification
Form is used for hospice identification, screening, and to initiate the
certification process. The information captured on this form is entered
into a data base which assists CMS in determining whether providers
have sufficient personnel to participate in the Medicare program;
Frequency: Annually; Affected Public: Business or other for-profit,
Not-for-profit institutions, Federal Government, and State, local or
tribal government; Number of Respondents: 2,286; Total Annual
Responses: 2,286; Total Annual Hours: 430.
4. Type of Information Collection Request: New collection; Title of
Information Collection: End Stage Renal Disease Hemodialysis Patient
Experience of Care (CAHPS) Survey; Form No.: CMS-10105 (OMB
0938-NEW; Use: The ESRD CAHPS Hemodialysis Patient Experience of Care
Survey follows CMS CAHPS efforts in other provider areas (Managed Care,
FFS, hospital), and is intended to provide CMS with a picture of the
experience of this vulnerable population who receive life sustaining
dialysis therapy approximately three times per week from dialysis
facilities. A variety of patient satisfaction surveys are already
conducted regularly by a many dialysis organizations (although the
majority of instruments have not been tested) and this tool would
provide the ESRD community with a tested, standardized survey
instrument that facilities could use for quality improvement and
comparative purposes. It will provide information for consumer choice,
data that facilities can use for internal quality improvement and
external benchmarking against other facilities, and finally,
information that CMS can use for public reporting and monitoring
purposes. CMS has not yet determined if it will mandate the collection
of this information. Potential approaches for national implementation
are under consideration.; Frequency: On occasion; Affected Public:
Individuals or Households; Number of Respondents: 1,800; Total Annual
Responses: 1,800; Total Annual Hours: 460.
5. Type of Information Collection Request: New collection; Title of
Information Collection: Medicare Authorization to Disclose Health
Information; Form No.: CMS-10106 (OMB 0938-NEW; Use: Unless
permitted or required by law, the Privacy Act and Health Insurance
Portability and Accountability Act (HIPAA) Privacy Rule prohibit
covered entities from disclosing an individual's protected health
information to a third party without a valid privacy authorization. The
authorization must include specified core elements and certain
statements. Medicare beneficiaries will use the ``Medicare
Authorization to Disclose Health Information'' to authorize Medicare to
disclose their protected health information to a third party.;
Frequency: Other: an event basis; Affected Public: Individuals or
Households; Number of Respondents: 39,000,000; Total Annual Responses:
1,000,000; Total Annual Hours: 250,000.
To obtain copies of the supporting statement and any related forms
for the proposed paperwork collections referenced above, access CMS's
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 60 days of this notice directly to the CMS Paperwork Clearance
Officer designated at the following address: CMS, Office of Strategic
Operations and Regulatory Affairs, Division of Regulations Development
and Issuances, Attention: Melissa Musotto, Room C5-14-03, 7500 Security
Boulevard, Baltimore, Maryland 21244-1850.
Dated: January 22, 2004.
Melissa Musotto,
Acting Paperwork Reduction Act Team Leader, Office of Strategic
Operations and Strategic Affairs, Division of Regulations Development
and Issuances.
[FR Doc. 04-1983 Filed 1-29-04; 8:45 am]
BILLING CODE 4120-03-P