[Federal Register Volume 65, Number 127 (Friday, June 30, 2000)]
[Notices]
[Page 40668]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-16595]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

[Document Identifier: HCFA-1763]


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 Termination of Premium 
Hospital and/or Supplementary Medical Insurance and Supporting 
Regulations in 42 CFR 406.28 and 407.27;
    Form No.: HCFA-1763 (OMB No. 0938-0025);
    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, Federal Government, and 
State, Local or Tribal Government;
    Number of Respondents: 14,000;
    Total Annual Responses: 14,000;
    Total Annual Hours: 5,833.
    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 [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: June 22, 2000.
John P. Burke III,
HCFA Reports Clearance Officer, HCFA Office of Information Services, 
Security and Standards Group, Division of HCFA Enterprise Standards.
[FR Doc. 00-16595 Filed 6-29-00; 8:45 am]
BILLING CODE 4120-03-P