04-1983. 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 [e-mail], or call the Reports Clearance Office on [phone]. 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.