04-18619. Agency Information Collection Activities: Submission for OMB Review; Comment Request

AGENCY:

Centers for Medicare & 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 & 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: Revision of a currently approved collection.

Title of Information Collection: Conflict of Interest and Ownership and Control Information.

Form No.: CMS-R-312 (OMB #: 0938-0795).

Use: This information is required by Public Law 95-142 as a condition of participation in the Medicare program. The Fiscal Intermediaries and Carriers are contractually required as a condition for renewal of their contracts to submit to CMS any ownership and control interest information.

Frequency: Annually.

Affected Public: Not-for-profit institutions and Business or other for-profit.

Number of Respondents: 37.

Total Annual Responses: 37.

Total Annual Hours: 11,100.

2. Type of Information Collection Request: Extension of a currently approved collection.

Title of Information Collection: CLIA Budget Workload Reports and Supporting Regulations Contained in 42 CFR 493.1-.2001.

Form No.: CMS-102 and CMS-105.

OMB #: 0938-0599.

Use: Information collected will be used by CMS in determining the amount of Federal Reimbursement for compliance surveys. Use of the information includes program evaluation, audit, budget formulation, and budget approval.

Frequency: Quarterly and Annually.

Affected Public: State, Local, or Tribal Government.

Number of Respondents: 50.

Total Annual Responses: 50.

Total Annual Hours: 4,500.

3. Type of Information Collection Request: Extension of a currently approved collection.

Title of Information Collection: Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.7.

Form No.: CMS-18F5.

OMB #: 0938-0251.

Use: The CMS-18F5 is used to establish entitlement to Hospital Insurance and Supplementary Medical Insurance for beneficiaries entitled under Title XVIII of the Social Security Act. The HCFA-18F5-SP is included in this renewal. (The Agency name change on the Spanish language form has not been done because there is still stock on hand.)

Frequency: On occasion.

Affected Public: Individuals or Households, Business or other for-profit, Not-for-profit institutions, Farms, Federal government, and State, local, or tribal gov.

Number or Respondents: 50,000.

Total Annual Responses: 50,000.

Total Annual Hours: 12,500.

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://www.cms.hhs.gov/​regulations/​pra/​, 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 at [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: Christopher Martin, New Executive Office Building, Room 10235, Washington, DC 20503.

Dated: August 6, 2004.

John P. Burke, III,

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