[Federal Register Volume 69, Number 30 (Friday, February 13, 2004)]
[Notices]
[Pages 7230-7231]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-3161]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[Document Identifier: CMS-R-235, CMS-179, CMS-265]


Agency Information Collection Activities: Proposed Collection; 
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: Data Use 
Agreement Information Collection Requirements, model language, and 
supporting regulations in 45 CFR Section 5b.; Form No.: CMS-R-235 
(OMB 0938-0734); Use: Binding agreement stating conditions 
under which CMS will disclose and user will maintain CMS data that are 
protected by the Privacy Act.; Frequency: On occasion; Affected Public: 
Not-for-profit institutions; Number of Respondents: 1,500; Total Annual 
Responses: 1,500; Total Annual Hours: 750.
    2. Type of Information Request: Extension of a currently approved 
collection; Title of Information Collection: Transmittal and Notice of 
Approval of State Plan Material and Supporting Regulations in 42 CFR 
430.10-430.20 and 440.167; Form Number: CMS-179 (OMB approval 
: 0938-0193);  Use: Form CMS-179 is used by State agencies to 
transmit State plan material to CMS for approval prior to amending 
their State plans; Frequency: On occasion; Affected Public: State, 
local or tribal gov't; Number of Respondents: 56; Total Annual 
Responses: 56; Total Annual Hours Requested: 560.
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Independent Renal 
Dialysis Facility Cost Report Form and Supporting Regulations in 42 CFR 
413.20, 413.24; Form No.: CMS-265 (OMB 0938-0236); Use: The 
Medicare Independent Renal Dialysis Facility Cost Report provides for 
determinations and allocation of costs to the components of the Renal 
Dialysis facility in order to establish a proper basis for Medicare 
payment; Frequency: Annually; Affected Public: Business or other for-
profit, not-for-profit institutions, and State, Local, or Tribal 
Government; Number of Respondents: 3,592; Total Annual Responses: 
3,592; Total Annual Hours: 704,032.
    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

[[Page 7231]]

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: February 5, 2004.
John P. Burke, III,
Paperwork Reduction Act Team Leader, Office of Strategic Operations and 
Strategic Affairs, Division of Regulations Development and Issuances.
[FR Doc. 04-3161 Filed 2-12-04; 8:45 am]
BILLING CODE 4120-03-P