[Federal Register Volume 65, Number 9 (Thursday, January 13, 2000)]
[Notices]
[Page 2186]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-841]



[[Page 2186]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

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


Agency Information Collection Activities: Submission For OMB 
Review; 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, has 
submitted to the Office of Management and Budget (OMB) the following 
proposal 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.
    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 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 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 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: December 22, 1999.
John Parmigiani,
Manager, HCFA, Office of Information Services, Security and Standards 
Group, Division of HCFA Enterprise Standards.
[FR Doc. 00-841 Filed 1-12-00; 8:45 am]
BILLING CODE 4120-03-P