[Federal Register Volume 59, Number 85 (Wednesday, May 4, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-10635]
[[Page Unknown]]
[Federal Register: May 4, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
Public Information Collection Requirements Submitted to the
Office of Management and Budget (OMB) for Clearance
AGENCY: Health Care Financing Administration, HHS.
The Health Care Financing Administration (HCFA), Department of
Health and Human Services (HHS), has submitted to OMB the following
proposals for the collection of information in compliance with the
Paperwork Reduction Act (Public Law 96-511).
1. Type of Request: New; Title of Information Collection: Clinical
Laboratory Improvement Amendments (CLIA), Flexible Survey Protocol
Form; Form No.: HCFA-667; Use: This form will be used for laboratories
that are nonwaived, nonaccredited, and considered low risk by HCFA, in
lieu of onsite inspection for the first survey cycle. This checklist is
designed to screen laboratories and alert HCFA to any facility where an
onsite inspection is vital; Frequency: Biennially; Respondents: State
or local governments, Federal agencies or employees, small businesses
or organizations, and nonprofit institutions; Estimated Number of
Responses: 1,000; Average Hours Per Response: 1.5; Total Estimated
Burden Hours: 1,500.
2. Type of Request: Extension; Title of Information Collection:
Application for Health Insurance Benefits Under Medicare for Individual
With Chronic Renal Disease; Form No.: HCFA-43; Use: The law requires
the filing of an application to establish Medicare entitlement based on
end stage renal disease. This form is the application form used to
obtain information needed to determine Medicare eligibility. It guides
district office personnel in securing the required development and
becomes a permanent part of the claims file; Frequency: On occasion;
Respondents: Individuals or households; Estimated Number of Responses:
21,000; Average Hours Per Response: .43; Total Estimated Burden Hours:
9,030.
3. Type of Request: Reinstatement; Title of Information Collection:
Medicare Qualification Statement for Federal Employees; Form No.: HCFA-
565; Use: Information is required on individuals filing for hospital
insurance benefits (Part A) based on their Federal employment. This
information is required in order to determine if they can get
``deemed'' quarters for work prior to 1983 to qualify for free Part A;
Frequency: One time only; Respondents: Individuals or households;
Estimated Number of Responses: 4,300; Average Hours Per Response: .17;
Total Estimated Burden Hours: 731.
4. Type of Request: Reinstatement; Title of Information Collection:
Attending Physician's Statement and Documentation of Medicare
Emergency; Form No.: HCFA-1771; Use: This form is used to document the
attending physician's statement that the hospitalization was required
due to an emergency and give clinical support for the claim; Frequency:
On occasion; Respondents: Businesses or other for profit; Estimated
Number of Responses: 1,700; Average Hours Per Response: .25; Total
Estimated Burden Hours: 425.
5. Type of Request: Reinstatement; Title of Information Collection:
Request for Part B Medicare Hearing by an Administrative Law Judge;
Form No.: HCFA-5011B; Use: This form is used by the beneficiary or
other qualified appellant to request a hearing by an Administrative Law
Judge if the carrier hearing decision fails to satisfy the claimant;
Frequency: On occasion; Respondents: Businesses or other for profit,
individuals or households; Estimated Number of Responses: 10,000;
Average Hours Per Response: .25; Total Estimated Burden Hours: 2,500.
6. Type of Request: Reinstatement; Title of Information Collection:
Request for Part A Medicare Hearing by an Administrative Law Judge;
Form No.: HCFA-5011A; Use: This form is used by the beneficiary or
other qualified appellant to request a hearing by an Administrative Law
Judge if the carrier hearing decision fails to satisfy the claimant;
Frequency: On occasion; Respondents: Businesses or other for profit,
individuals or households; Estimated Number of Responses: 10,000;
Average Hours Per Response: .25; Total Estimated Burden Hours: 2,500.
7. Type of Request: New; Title of Information Collection: Clinical
Laboratory Improvement Amendments (CLIA) Adverse Action Extract; Form
No.: HCFA-462; Use: The CLIA Adverse Action Extract will be used by
HCFA surveyors (State health department surveyors and other HCFA
agents) to record the adverse actions imposed against a laboratory. The
form will also serve to track dates of the imposition of adverse
actions, dates on which a laboratory corrects deficiencies, and all
appeals activity; Frequency: Biennially or when adverse actions are
imposed against a laboratory; Respondents: State or local governments,
Federal agencies or employees, nonprofit institutions, small businesses
or organizations; Estimated Number of Responses: 2,500 (reporting) 52
States (recordkeeping); Average Hours Per Response: 2.25 (reporting),
1.90 (recordkeeping); Total Estimated Burden Hours: 5,724.
8. Type of Request: New; Title of Information Collection: Medicare
and Medicaid Coverage Data Bank Reports; Form No.: HCFA-163; Use:
Employers are required to report information on individuals covered by
the employer's group health plans to a data bank established by HHS.
Information will be used to further purposes of Medicare Secondary
Payer and Medicaid Third Party Liability provisions of the Social
Security Act; Frequency: Annually; Respondents: State or local
governments, Federal agencies or employees, nonprofit institutions,
small businesses or organizations, individuals or households; Estimated
Number of Responses: 120,000,000 (reporting), 10,000 (recordkeeping);
Average Hours Per Response: 3.89 seconds (reporting), 100 hours
(recordkeeping); Total Estimated Burden Hours: 2,300,000.
Additional Information or Comments: Call the Reports Clearance
Office on (410) 966-5536 for copies of the clearance request packages.
Written comments and recommendations for the proposed information
collections should be sent within 30 days of this notice directly to
the OMB Desk Officer designated at the following address: OMB Human
Resources and Housing Branch, Attention: Allison Eydt, New Executive
Office Building, Room 3001, Washington, DC 20503
Dated: April 25, 1994.
John A. Streb,
Director, Management Planning and Analysis Staff, Office of Financial
and Human Resources, Health Care Financing Administration.
[FR Doc. 94-10635 Filed 5-3-94; 8:45 am]
BILLING CODE 4120-03-P
