03-31357. Agency Information Collection Activities: Submission for OMB Review; 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: Psychiatric Unit Criteria Worksheet, Rehabilitation Unit Criteria Worksheet, and Rehabilitation Hospital Criteria Worksheet, and Supporting Regulations at 42 CFR 488.26; Form No.: CMS-437, 437A, and 437B (OMB# 0938-0358); Use: The rehabilitation hospital/unit and psychiatric unit criteria worksheets are necessary to verify and reverify that these facilities/units comply and remain in compliance with the exclusion criteria for the Medicare prospective payment system; Frequency: Annually; Affected Public: Business or other-for-profit, not-for-profit institutions; Number of Respondents: 2,610; Total Annual Responses: 2,610; Total Annual Hours: 653.

2. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Municipal Health Services Cost Report Form and supporting Regulations 42 CFR 405.2470; Form No.: CMS-255 (OMB# 0938-0155); Use: The Municipal Health Services Program Cost Report (CMS 255) is used by the participating clinics to report costs for health care services rendered to Medicare beneficiaries. It is also used to gather data to properly evaluate the demonstration; Frequency: Annually; Affected Public: Not-for-profit institutions; Number of Respondents: 14; Total Annual Responses: 14; Total Annual Hours: 476.

3. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Medicaid Report on Payables and Receivables; Form No.: CMS-R-199 (OMB# 0938-0697); Use: The Chief Financial Officers Act of 1990 requires government agencies to produce auditable financial statements. This form will collect accounting data from the States on Payables and Receivables; Frequency: Annually; Affected Public: State, local or tribal government; Number of Respondents: 57; Total Annual Responses: 57; Total Annual Hours: 342.

4. Type of Information Request: Extension of a currently approved collection; Type of Information Collection: Medicaid Program: Real Choice Systems Change Grants for Community Living; CMS Form Number: CMS-10086 (OMB# 0938-0901); Use: Executive Order 13217, “Community-Based Alternatives for Individuals with Disabilities” called upon the Federal government to assist States and localities to swiftly implement the decision of the United States Supreme Court in Olmstead v. L.C., stating: “The United States is committed to community-based alternatives for individuals with disabilities and recognizes that such services advance the best interests of the United States.” State agencies and community groups will be applying for these grants; Frequency: On occasion; Affected Public: State, local, or tribal government; not-for-profit institutions; Number of Respondents: 75; Total Annual Responses: 150; Total Annual Burden Hours: 1500.

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 [e-mail], or call the Reports Clearance Office on [phone]. 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: December 12, 2003.

Julie Brown,

Acting, Paperwork Reduction Act Team Leader, CMS Reports Clearance Officer, Office of Strategic Operations and Strategic Affairs, Division of Regulations Development and Issuances.