[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