[Federal Register Volume 61, Number 197 (Wednesday, October 9, 1996)]
[Notices]
[Page 52951]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-25833]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[HCFA-R-72]


Agency Information Collection Activities: Submission for OMB 
Review; Comment Request

AGENCY: Health Care Financing Administration, HHS.
    In compliance with the Paperwork Reduction Act of 1995 (44 U.S.C. 
3501 et seq.), the Health Care Financing Administration (HCFA), 
Department of Health and Human Services, has submitted to the Office of 
Management and Budget (OMB) the following proposals for the collection 
of information. 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.
    1. Type of Information Collection Request: Reinstatement, without 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Information Collection 
Requirements in 42 CFR 473.18 (a) and (b), 473.34 (a) and (b), 473.36 
(a) and (b), and 473.42 (a), Peer Review Organization (PRO) 
Reconsideration and Appeals ; Form No.: HCFA-R-72; Use: These 
regulations contain procedures for PRO's to use in reconsideration of 
initial determinations. The information requirements contained in these 
regulations are on PROs to provide information to parties requesting a 
reconsideration review. These parties will use the information as 
guidelines for appeal rights in instances where issues are still in 
dispute; Frequency: On occasion; Affected Public: Business or other for 
profit; Number of Respondents: 53; Total Annual Responses: 15,670; 
Total Annual Hours: 3,578.
    2. Type of Information Collection Request: Reinstatement, without 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Request for Enrollment in 
Supplementary Medical Insurance; Form No.: HCFA-4040; Use: The HCFA-
4040 is used to establish entitlement to Supplementary Medical 
Insurance by Beneficiaries not eligible under Part A of Title XVIII or 
Title II of the Social Security Act. The HCFA-4040SP is the Spanish 
edition of this form; Frequency: One time only; Affected Public: 
Individuals and households, Federal government, State, local, or tribal 
governments; Number of Respondents: 10,000; Total Annual Responses: 
10,000; Total Annual Hours: 2,500.
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Request for 
Certification as a Rural Health Clinic, Rural Health Clinic Survey 
Report Form; Form No.: HCFA-29, 30; Use: The form HCFA-29 ``Request for 
Certification as a Rural Health Clinic'' is used by facilities to apply 
to participate in the Medicare program. The form HCFA-30 ``Rural Health 
Clinic Survey Report Form, is used by State survey agencies to record 
data needed to determine compliance with the Federal requirements; 
Frequency: Annually; Affected Public: State , local or tribal 
governments; Number of Respondents: 390; Total Annual Responses: 390; 
Total Annual Hours: 682.
    4. Type of Information Collection Request: Reinstatement, without 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Quarterly Showing; Form No.: 
HCFA-R-41; Use: This form is used by State Medicaid agencies to list 
participating health care facilities and the dates the State agencies 
reviewed the facilities. The lists are required to assure the existence 
of an effective utilization (of services) control program, as required 
by law and regulation, to avoid a penalty; Frequency: Quarterly; 
Affected Public: State, local or tribal governments; Number of 
Respondents: 47; Total Annual Responses: 188; Total Annual Hours: 
9,212.
    5. Type of Information Collection Request: Reinstatement, without 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Quarterly Showing Validation 
Survey; Form No.: HCFA-9050; Use: Reporting entities may be required to 
submit lists of Medicaid beneficiaries residing in a select number of 
institutions. State Medicaid agencies may also be required to submit 
procedures for conducting inspection of care reviews and other 
documentation necessary to validate the Quarterly Showing reports. The 
listings are required to determine those patients for which the State 
is currently responsible for their care. This part of the operation to 
determine that states have an effective utilization control program; 
Frequency: Annually; Affected Public: State, local or tribal 
governments; Number of Respondents: 47; Total Annual Responses: 8; 
Total Annual Hours: 376.
    6. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Business Proposal 
Formats for Utilization and Quality Control Peer Review Organizations 
(PROs); Form No.: HCFA-718-721; Use: Submission of proposal information 
by current PROs and other bidders, according to the business proposal 
instructions, will satisfy HCFA's need for consistent, and verifiable 
data with which to validate contract proposals; Frequency: Other (Tri-
annually); Affected Public: Business or other for profit, not for 
profit institutions; Number of Respondents: 20; Total Annual Responses: 
23; Total Annual Hours: 450.
    To obtain copies of the supporting statement and any related forms, 
E-mail your request, including your address and phone number, to 
P[email protected], or call the Reports Clearance Office on (410) 786-
1326. 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 10235, Washington, D.C. 20503.

    Dated: October 2, 1996.
Edwin J. Glatzel,
Director, Management Analysis and Planning Staff, Office of Financial 
and Human Resources, Health Care Financing Administration.
[FR Doc. 96-25833 Filed 10-8-96; 8:45 am]
BILLING CODE 4120-03-P