[Federal Register Volume 62, Number 111 (Tuesday, June 10, 1997)]
[Notices]
[Pages 31612-31613]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-15120]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[HCFA-1763]


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.

[[Page 31613]]

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.
    Type of Information Collection Request: Reinstatement, with change, 
of a previously approved collection for which approval has expired; 
Title of Information Collection: Request for Termination of Premium 
Hospital and/or Supplementary Medical Insurance and Supporting 
Regulations in 42 CFR 406.28 and 407.27; Form No.: HCFA-1763; Use: The 
HCFA-1763 is used by beneficiaries to request voluntary termination 
from premium hospital and/or supplementary medical insurance. 
Frequency: One time only; Affected Public: Individuals or Households 
and Federal Government; Number of Respondents: 14,000; Total Annual 
Hours: 7,000.
    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: June 4, 1997.
Edwin J. Glatzel,
Director, Management Analysis and Planning Staff Office of Financial 
and Human Resources.
[FR Doc. 97-15120 Filed 6-9-97; 8:45 am]
BILLING CODE 4120-03-P