[Federal Register Volume 64, Number 199 (Friday, October 15, 1999)]
[Notices]
[Pages 55948-55949]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-26996]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[Document Identifier: HCFA-4040]


Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Health Care Financing Administration, HHS.
    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 this 
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: Extension of a currently 
approved collection;
    Title of Information Collection: Request for Enrollment in 
Supplementary Medical Insurance and Supporting Regulations in 42 CFR 
407.10 and 407.11;
    Form No.: HCFA-4040 (OMB #0938-0245);
    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: Other: One Time Only;
    Affected Public: Individuals or Households, Federal Government, and 
State, Local or Tribal Government;
    Number of Respondents: 10,000;
    Total Annual Responses: 10,000;
    Total Annual Hours: 2,500.
    To obtain copies of the supporting statement and any related forms 
for the proposed paperwork collections referenced above, access HCFA's 
Web Site address at http://www.hcfa.gov/regs/prdact95.htm, or E-mail 
your request, including your address, phone number, OMB number, and 
HCFA document identifier, to

[[Page 55949]]

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 Information Services, Security and Standards 
Group, Division of HCFA Enterprise Standards; Attention: Dawn 
Willinghan, Room N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 
21244-1850.

    Dated: October 6, 1999.
John Parmigiani,
Manager, HCFA Office of Information Services, Security and Standards 
Group, Division of HCFA Enterprise Standards.
[FR Doc. 99-26996 Filed 10-14-99; 8:45 am]
BILLING CODE 4120-03-P