[Federal Register Volume 69, Number 30 (Friday, February 13, 2004)]
[Notices]
[Pages 7229-7230]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-3160]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[Document Identifier: CMS-1491, CMS-R-26, CMS-1728, CMS-2540 and CMS-
10098]


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: Request for 
Medicare Payment--Ambulance and Supporting Regulations in 42 CFR 
Sections 410.1, 410.40, 424.124, 414.601, 414.605, 414.610, 414.611, 
414.615, 414.620, and 414.625.; Form No.: CMS-1491 (OMB 0938-
0042); Use: This paper form is completed on an occasion basis by 
beneficiaries and/or ambulance suppliers. Also, it is submitted to a 
Medicare carrier to request payment for ambulance services.; Frequency: 
On occasion; Affected Public: Business or other for-profit, individuals 
or households, and not-for-profit institutions; Number of Respondents: 
9,301,183; Total Annual Responses: 9,301,183; Total Annual Hours: 
331,643.
    2. Type of Information Request: Revision of a currently approved 
collection; Title of Information Collection: Information Collection 
Requirements (ICR) Contained in the Clinical Laboratory Improvement 
Amendments (CLIA) Regulations 42 CFR part 493.801, 493.803, 493.1232, 
493.1233, 493.1234, 493.1235, 493.1236, 493.1239, 493.1241, 493.1242, 
493.1249, 493.1251, 493,1252, 493.1253, 493.1254, 493.1255, 493.1256, 
493.1261, 493.1262, 493.1263, 493.1269, 493.1273, 493.1274, 493.1278, 
493.1283, 493.1289, 493.1291, and 493.1299; Form Number: CMS-R-26 (OMB 
approval : 0938-0612); Use: The ICRs referenced in specified 
sections of 42 CFR part 493 outline the requirements necessary to 
determine an entity's compliance with CLIA. CLIA requires laboratories 
that perform testing on human beings to meet performance requirements 
(quality

[[Page 7230]]

standards) in order to be certified by HHS; Frequency: Other: As 
needed; Affected Public: Business or other for-profit, not-for-profit 
institutions, Federal government, State, local or tribal gov't; Number 
of Respondents: 82,220; Total Annual Responses: 111,354,920; Total 
Annual Hours Requested: 9,887,917.
    3. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Home Health 
Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24 
and 413.106; Form No.: CMS-1728 (OMB 0938-0022); Use: 
Participating providers are required to submit annual information to 
CMS in order to achieve settlement of costs for health care services 
rendered to Medicare beneficiaries. The CMS-1728 is the form used by 
Home Health Agencies to report their health care costs to determine the 
amount reimbursable for services furnished to Medicare beneficiaries; 
Frequency: Annually; Affected Public: Business or other for profit, not 
for profit institutions, and State, Local or Tribal Gov.; Number of 
Respondents: 7,310; Total Annual Responses: 7,310; Total Annual Hours 
Requested: 1,311,060.
    4. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Skilled Nursing 
Facility Cost Report and Supporting Regulations in 42 CFR 413.20, 
413.24, and 413.106; Form No.: CMS-2540-96 (OMB 0938-0463); Use: Form 
CMS-2540-96 is the form used by skilled nursing facilities 
participating in the Medicare program. This form reports the health 
care costs used to determine the amount of reimbursable costs for 
services rendered to Medicare beneficiaries; Frequency: Annually; 
Affected Public: Businesses or other for-profit; not-for-profit 
institutions and State, Local or Tribal Government; Number of 
Respondents: 13,000; Total Annual Responses: 13,000; Total Annual 
Hours: 2,480,000.
    5. Type of Information Collection Request: New Collection; Title of 
Information Collection: 1-800-Medicare Beneficiary Satisfaction Survey; 
Form No.: CMS-10098 (OMB 0938-NEW); Use: The Beneficiary 
Satisfaction survey is performed to insure that the CMS 1-800-Medicare 
helpline contractor is delivering satisfactory service to the Medicare 
beneficiaries. It gathers data on several helpline operations such as 
print fulfillment and website tools hosted on http://www.medicare.gov. 
Respondents to the survey are Medicare beneficiaries that have 
contacted the 1-800-Medicare number within the past week for benefits 
and services information.; Frequency: On occasion; Affected Public: 
Individuals or households; Number of Respondents: 14,400; Total Annual 
Responses: 14,400; Total Annual Hours: 1,800.
    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: February 5, 2004.
John P. Burke, III,
Paperwork Reduction Act Team Leader, CMS Reports Clearance Officer, 
Office of Strategic Operations and Strategic Affairs, Division of 
Regulations Development and Issuances.
[FR Doc. 04-3160 Filed 2-12-04; 8:45 am]
BILLING CODE 4120-03-P