[Federal Register Volume 68, Number 75 (Friday, April 18, 2003)]
[Notices]
[Pages 19210-19211]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-9548]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[Document Identifier: CMS-R-242, CMS-1763, CMS-4040-SP, CMS-10069, CMS-
R-52, CMS-R-30]


Agency Information Collection Activities: Submission for OMB 
Review; Comment Request

AGENCY: Centers for Medicare and Medicaid Services, HHS.
    In compliance with the requirement of section 3506(c)(2)(A) of the 
Paperwork Reduction Act of 1995, the Centers for Medicare and Medicaid 
Services (CMS) (formerly known as 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.
    1. Type of Information Collection Request: Extension of a currently 
approved collection.
    Title of Information Collection: Refinement of RHC Certification 
and QAPI and Supporting Regulations in 42 CFR 491.8 and 491.11.
    Form No.: CMS-R-242 (OMB 0938-0792).
    Use: This collection contains information collection requirements 
concerning requests for additional waivers of staffing requirements and 
documentation of quality assessment and performance improvement 
programs.
    Frequency: Annually.
    Affected Public: Business or other for-profit.
    Number of Respondents: 3,528.
    Total Annual Responses: 3,573.
    Total Annual Hours: 3,663.
    2. 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.
    Form No.: CMS-1763 (OMB 0938-0025).
    Use: The CMS-1763 is used by beneficiaries to request voluntary 
termination from Premium Hospital Insurance (premium-HI) and/or 
Supplementary Medicare Insurance (SMI).
    Frequency: One time only.
    Affected Public: Individuals or Households, Federal Government, 
State, local, and tribal government.
    Number of Respondents: 14,000.
    Total Annual Responses: 14,000.
    Total Annual Hours: 5,833.
    3. Type of Information Collection Request: Extension of a currently 
approved collection.
    Title of Information Collection: Request for Enrollment in 
Supplemental Medicare Insurance and Supporting Regulations in 42 CFR 
407.10 and 401.11.
    Form No.: CMS-4040 and 4040-SP (OMB 0938-0245).
    Use: The CMS 4040 is used to establish entitlement to Supplemental 
Medical Insurance (Part B) by beneficiaries not eligible under Part A 
of the Title XVIII or Title II of the Social Security Act. The CMS-
4040SP is also included in this renewal.
    Frequency: One time only.
    Affected Public: Individuals or Households, Federal Government, 
State, local, and tribal government.
    Number of Respondents: 10,000.
    Total Annual Responses: 10,000.
    Total Annual Hours: 2,500.
    4. Type of Information Collection Request: Extension of a currently 
approved collection.
    Title of Information Collection: Medicare Waiver Demonstration 
Application.
    Form No.: CMS-10069 (OMB 0938-0880).
    Use: The Medicare Waiver Demonstration Application will be used to 
collect standard information needed to implement Congressionally 
mandated

[[Page 19211]]

and administration high priority demonstrations. The application will 
be used to gather information about the characteristics of the 
applicant's organization, benefits, and services they propose to offer, 
success in operating the model, and evidence that the model is likely 
to be successful in the Medicare program. The standard application will 
be used for all waiver demonstrations and will reduce the burden on 
applicants, provide for consistent and timely information collections 
across demonstration, and provide a user-friendly format for 
respondents.
    Frequency: On Occasion.
    Affected Public: Business or other for-profit and Not-for-profit 
institutions.
    Number of Respondents: 75.
    Total Annual Responses: 75.
    Total Annual Hours: 1600.
    5. Type of Information Collection Request: Extension of a currently 
approved collection.
    Title of Information Collection: Conditions of Coverage of 
Suppliers of End Stage Renal Disease (ESRD).
    Form No.: CMS-R-52 (OMB 0938-0386).
    Use: This package is needed to encourage proper distribution and 
effective utilization of ESRD treatment sources while maintaining and 
improving the efficient delivery of care by physicians and dialysis 
facilities.
    Frequency: Annually.
    Affected Public: Business or other for-profit and Federal 
Government.
    Number of Respondents: 4,297.
    Total Annual Responses: 4,297.
    Total Annual Hours: 148,785.
    6. Type of Information Collection Request: Revision of a currently 
approved collection.
    Title of Information Collection: Information Collection 
Requirements in the Hospice Conditions Coverage. The following 
regulations are affected: 42 CFR 418.22; 418.24; 418.28; 418.56(b), 
(e)(1), (e)(3); 418.58; 418.70(e); 418.83; 418.96(b); and 418.100(b).
    Form No.: CMS-R-30 (OMB 0938-0302).
    Use: Establishes standards for hospices that wish to participate in 
the Medicare program. The regulations establish standards for 
eligibility, reimbursement standards and procedure, and delineate 
conditions that hospices must meet to be approved for participation in 
Medicare.
    Frequency: On occasion.
    Affected Public: Business or other for-profit.
    Number of Respondents: 2,316.
    Total Annual Responses: 2,316.
    Total Annual Hours: 5,981,427.
    To obtain copies of the supporting statement and any related forms 
for the proposed paperwork collections referenced above, access CMS Web 
site address at http://cms.hhs.gov/regulations/pra/default.asp, or e-
mail your request, including your address, phone number, OMB number, 
and CMS 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 30 days of this notice directly to the OMB desk officer: OMB 
Human Resources and Housing Branch, Attention: Brenda Aguilar, New 
Executive Office Building, Room 10235, Washington, DC 20503.

    Dated: April 10, 2003.
Dawn Willinghan,
Acting Paperwork Reduction Act Team Leader, CMS Reports Clearance 
Officer, Office of Strategic Operations and Regulatory Affairs, 
Division of Regulations Development and Issuances.
[FR Doc. 03-9548 Filed 4-17-03; 8:45 am]
BILLING CODE 4120-03-P