[Federal Register Volume 69, Number 20 (Friday, January 30, 2004)]
[Notices]
[Page 4520]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-1983]



[[Page 4520]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[Document Identifier: CMS-1561; CMS-367, 367a, and 367c; CMS-417; CMS-
10105 and CMS-10106]


Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Centers for Medicare and Medicaid Services.
    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: Health Insurance 
Benefit Agreement and Supporting Regulations in 42 CFR Section 489; 
Form No.: CMS-1561 (OMB 0938-0832); Use: Applicants to the 
Medicare program are required to agree to provide services in 
accordance with Federal requirements. The CMS-1561 is essential for CMS 
to ensure that applicants are in compliance with the requirements. 
Applicants will be required to sign the completed form and provide 
operational information to CMS to assure that they continue to meet the 
requirements after approval; Frequency: Other: as needed; Affected 
Public: Business or other for-profit, Not-for-profit institutions, and 
State, Local or Tribal Government; Number of Respondents: 3,000; Total 
Annual Responses: 3,000; Total Annual Hours: 150.
    2. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Medicaid Drug 
Rebate Program--Manufacturers; Form No.: 0938-0578 (CMS-367, 367a, and 
367c); Use: Section 1927 requires drug manufacturers to enter into and 
have in effect a rebate agreement with the Federal Government for 
States to receive funding for drugs dispensed to Medicaid recipients; 
Frequency: Quarterly; Affected Public: Business or other for-profit; 
Number of Respondents: 551; Total Annual Responses: 2,204; Total Annual 
Hours: 54,660.
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Hospice Request 
for Certification in the Medicare Program; Form No.: CMS-417 
(OMB 0938-0313); Use: The Hospice Request for Certification 
Form is used for hospice identification, screening, and to initiate the 
certification process. The information captured on this form is entered 
into a data base which assists CMS in determining whether providers 
have sufficient personnel to participate in the Medicare program; 
Frequency: Annually; Affected Public: Business or other for-profit, 
Not-for-profit institutions, Federal Government, and State, local or 
tribal government; Number of Respondents: 2,286; Total Annual 
Responses: 2,286; Total Annual Hours: 430.
    4. Type of Information Collection Request: New collection; Title of 
Information Collection: End Stage Renal Disease Hemodialysis Patient 
Experience of Care (CAHPS) Survey; Form No.: CMS-10105 (OMB 
0938-NEW; Use: The ESRD CAHPS Hemodialysis Patient Experience of Care 
Survey follows CMS CAHPS efforts in other provider areas (Managed Care, 
FFS, hospital), and is intended to provide CMS with a picture of the 
experience of this vulnerable population who receive life sustaining 
dialysis therapy approximately three times per week from dialysis 
facilities. A variety of patient satisfaction surveys are already 
conducted regularly by a many dialysis organizations (although the 
majority of instruments have not been tested) and this tool would 
provide the ESRD community with a tested, standardized survey 
instrument that facilities could use for quality improvement and 
comparative purposes. It will provide information for consumer choice, 
data that facilities can use for internal quality improvement and 
external benchmarking against other facilities, and finally, 
information that CMS can use for public reporting and monitoring 
purposes. CMS has not yet determined if it will mandate the collection 
of this information. Potential approaches for national implementation 
are under consideration.; Frequency: On occasion; Affected Public: 
Individuals or Households; Number of Respondents: 1,800; Total Annual 
Responses: 1,800; Total Annual Hours: 460.
    5. Type of Information Collection Request: New collection; Title of 
Information Collection: Medicare Authorization to Disclose Health 
Information; Form No.: CMS-10106 (OMB 0938-NEW; Use: Unless 
permitted or required by law, the Privacy Act and Health Insurance 
Portability and Accountability Act (HIPAA) Privacy Rule prohibit 
covered entities from disclosing an individual's protected health 
information to a third party without a valid privacy authorization. The 
authorization must include specified core elements and certain 
statements. Medicare beneficiaries will use the ``Medicare 
Authorization to Disclose Health Information'' to authorize Medicare to 
disclose their protected health information to a third party.; 
Frequency: Other: an event basis; Affected Public: Individuals or 
Households; Number of Respondents: 39,000,000; Total Annual Responses: 
1,000,000; Total Annual Hours: 250,000.
    To obtain copies of the supporting statement and any related forms 
for the proposed paperwork collections referenced above, access CMS's 
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 60 days of this notice directly to the CMS Paperwork Clearance 
Officer designated at the following address: CMS, Office of Strategic 
Operations and Regulatory Affairs, Division of Regulations Development 
and Issuances, Attention: Melissa Musotto, Room C5-14-03, 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850.

    Dated: January 22, 2004.
Melissa Musotto,
Acting Paperwork Reduction Act Team Leader, Office of Strategic 
Operations and Strategic Affairs, Division of Regulations Development 
and Issuances.
[FR Doc. 04-1983 Filed 1-29-04; 8:45 am]
BILLING CODE 4120-03-P