[Federal Register Volume 61, Number 217 (Thursday, November 7, 1996)]
[Notices]
[Pages 57688-57689]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-28621]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[Document Identifier: HCFA-3427]


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: Survey Report Form (CLIA), 
and supporting regulations 42 CFR 493.1 through 493.1804; Form No.: 
HCFA-1557; Use: Clinical Laboratory Certification and Recertification: 
This survey form is an instrument used by the State agency to record 
data collected in order to determine compliance with CLIA; Frequency: 
Biennially; Affected Public: Business or other for profit, not for 
profit institutions, Federal government and State, local or tribal 
governments; Number of Respondents: 30,225; Total Annual Hours: 16,322.
    2. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Laboratory 
Personnel Report (CLIA) and supporting regulations 42 CFR 493.1 through 
493.1804; Form No.: HCFA-209; Use: This form is used by the State 
agency to determine a laboratory's compliance with personnel 
qualifications under CLIA. This information is needed for a 
laboratory's CLIA certification and recertification; Frequency: 
Biennially; Affected Public: Business or other for profit, not for 
profit institutions, Federal, State, local or tribal governments; 
Number of Respondents: 26,250; Total Annual Hours: 13,125.
    3. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Medicare/Medicaid 
Hospital Survey Report Form and supporting regulations 42 CFR 482.1 
through 482.66; Form No.: HCFA-1537; Use: Section 1861(e) of the Social 
Security Act provides that hospitals participating in Medicare must 
meet specific requirements. These requirements are presented as 
conditions of participation. State agencies must determine compliance 
with these conditions through the use of this report form; Frequency: 
Annually; Affected Public: State, local or tribal governments; Number 
of Respondents: 1,322; Total Annual Hours Requested: 4,296.50.
    4. Type of Information Collection Request: Reinstatement, with 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Medicare Managed Care 
Disenrollment Form; Form No.: HCFA-566; Use: This form is used to 
process a beneficiaries request of disenrollment action from a health 
maintenance organization or competitive medical plan and to update the 
beneficiaries' health insurance master record; Frequency: On occasion; 
Affected Public: Individuals and households, business or other for 
profit, not for profit institutions, Federal government, State, local, 
or tribal governments; Number of Respondents: 24,000; Total Annual 
Responses: 24,000; Total Annual Hours: 792.
    5. Type of Information Collection Request: Reinstatement, without 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Ambulatory Surgical Center 
(ASC) Request for Certification and Survey Report and Supporting 
regulation 42 CFR 416; Form

[[Page 57689]]

No.: HCFA-377, HCFA-378; Use: The HCFA-377 is the application used by 
an ASC wanting to participate in the Medicare program. The HCFA-378 is 
the survey form used by State survey agencies to determine ASC 
compliance with individual conditions of coverage. 42 CFR 416 is the 
regulation supporting the data collected on the HCFA-377 and HCFA 378; 
Frequency: Annually; Affected Public: State, local, or tribal 
governments, business or other for profit, not-for-profit institutions; 
Number of Respondents: 1,900; Total Annual Responses: 1,900; Total 
Annual Hours: 475.
    6. Type of Information Collection Request: Reinstatement, without 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Medigap Complaint Database 
and Supporting Regulation 42 CFR 403.210 (b); Form No.: HCFA-R-156; 
Use: The Medigap database is maintained by the National Association of 
Insurance Commissioners, which in turn, sends the Medigap-relevant data 
to HCFA. The information is used to monitor State handling of Medigap 
related complaints; Frequency: Quarterly; Affected Public: Business or 
other for-profit; Number of Respondents: 1; Total Annual Responses: 4; 
Total Annual Hours: 160.
    7. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Comprehensive 
Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms 
and Information Collection Requirements in 42 CFR 485.56, 485.58, 
485.60; Form No.: HCFA-359, HCFA-360, HCFA-R-55; Use: In order to 
participate in the Medicare program as a CORF, providers must meet 
Federal conditions of participation. The certification form is needed 
to determine if providers meet at least preliminary requirements. The 
survey form is used to record provider compliance with the individual 
conditions and report findings to HCFA; Frequency: Annually; Affected 
Public: Business or other for profit, not for profit institutions, 
State, local, or tribal governments; Number of Respondents: 162; Total 
Annual Responses: 324; Total Annual Hours: 526 (reporting), 77,014 
(record keeping).
    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 28, 1996
Edwin J. Glatzel,
Director, Management Analysis and Planning Staff, Office of Financial 
and Human Resources, Health Care Financing Administration.
[FR Doc. 96-28621 Filed 11-6-96; 8:45 am]
BILLING CODE 4120-03-P