[Federal Register Volume 62, Number 94 (Thursday, May 15, 1997)]
[Notices]
[Page 26806]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-12764]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[HCFA-565 and HCFA-2384]


Agency Information Collection Activities: Proposed Collection; 
Comment Request

    In compliance with the requirement of section 3506(c)(2)(A) of the 
Paperwork Reduction Act of 1995, 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 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: Extension of a currently 
approved collection; Title of Information Collection: Medicare 
Qualification Statement for Federal Employees; Form No.: HCFA-565; Use: 
This form is completed by individuals filing for hospital insurance 
(HI) benefits (Part A) based upon their federal employment. This 
information is necessary to determine if HCFA/SSA can use federal 
employment prior to 1983 to qualify for free Part A. Frequency: One 
time only; Affected Public: Federal Government and Individuals or 
Households; Number of Respondents: 4,300; Total Annual Hours: 731.
    2. Type of Information Collection Request: Reinstatement, without 
change, of a previously approved collection for which approval has 
expired; Title of Information Collection: Third Party Premium Billing 
Request, 42 CFR 408.6; Form No.: HCFA-2384; Use: The Third Party 
Premium Billing Request is used as an authorization to designate that a 
family member or other interested party receive the Medicare Premium 
Bill and pay it on behalf of a Medicare beneficiary. Frequency: On 
occasion; Affected Public: Individuals or Households; Number of 
Respondents: 15,000; Total Annual Hours: 6,250.
    To obtain copies of the supporting statement for the proposed 
paperwork collections referenced above, access HCFA's WEB SITE ADDRESS 
at http://www.hcfa.gov/regs/prdact95.htm, or to obtain 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 must be mailed 
within 60 days of this notice directly to the HCFA Paperwork Clearance 
Officer designated at the following address: HCFA, Office of Financial 
and Human Resources, Management Analysis and Planning Staff, Attention: 
Louis Blank, Room C2-26-17, 7500 Security Boulevard, Baltimore, 
Maryland 21244-1850.

    Dated: May 7, 1997.
Edwin J. Glatzel,
Director, Management Analysis and Planning Staff,Office of Financial 
and Human Resources.
[FR Doc. 97-12764 Filed 5-14-97; 8:45 am]
BILLING CODE 4120-03-P