[Federal Register Volume 62, Number 111 (Tuesday, June 10, 1997)]
[Notices]
[Pages 31612-31613]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-15120]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[HCFA-1763]
Agency Information Collection Activities: Proposed Collection;
Comment Request
In compliance with the requirement of section 3506(c)(2)(A) of the
Paperwork Reduction Act of 1995, the Health Care Financing
Administration (HCFA), Department of Health and Human Services, is
publishing the following summary of proposed collections for public
comment.
[[Page 31613]]
Interested persons are invited to send comments regarding the 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.
Type of Information Collection Request: Reinstatement, with change,
of a previously approved collection for which approval has expired;
Title of Information Collection: Request for Termination of Premium
Hospital and/or Supplementary Medical Insurance and Supporting
Regulations in 42 CFR 406.28 and 407.27; Form No.: HCFA-1763; Use: The
HCFA-1763 is used by beneficiaries to request voluntary termination
from premium hospital and/or supplementary medical insurance.
Frequency: One time only; Affected Public: Individuals or Households
and Federal Government; Number of Respondents: 14,000; Total Annual
Hours: 7,000.
To obtain copies of the supporting statement for the proposed
paperwork collections referenced above, access HCFA's web site address
at http://www.hcfa.gov/regs/prdact95.htm, or to obtain the supporting
statement and any related forms, E-mail your request, including your
address and phone number, 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 HCFA Paperwork Clearance
Officer designated at the following address: HCFA, Office of Financial
and Human Resources, Management Analysis and Planning Staff, Attention:
Louis Blank, Room C2-26-17, 7500 Security Boulevard, Baltimore,
Maryland 21244-1850.
Dated: June 4, 1997.
Edwin J. Glatzel,
Director, Management Analysis and Planning Staff Office of Financial
and Human Resources.
[FR Doc. 97-15120 Filed 6-9-97; 8:45 am]
BILLING CODE 4120-03-P
