[Federal Register Volume 69, Number 161 (Friday, August 20, 2004)]
[Notices]
[Pages 51680-51681]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-18619]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-R-312, CMS-102/CMS-105, and CMS-18F5]


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

AGENCY: Centers for Medicare & 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 & 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: Revision of a currently 
approved collection.
    Title of Information Collection: Conflict of Interest and Ownership 
and Control Information.
    Form No.: CMS-R-312 (OMB : 0938-0795).

[[Page 51681]]

    Use: This information is required by Public Law 95-142 as a 
condition of participation in the Medicare program. The Fiscal 
Intermediaries and Carriers are contractually required as a condition 
for renewal of their contracts to submit to CMS any ownership and 
control interest information.
    Frequency: Annually.
    Affected Public: Not-for-profit institutions and Business or other 
for-profit.
    Number of Respondents: 37.
    Total Annual Responses: 37.
    Total Annual Hours: 11,100.
    2. Type of Information Collection Request: Extension of a currently 
approved collection.
    Title of Information Collection: CLIA Budget Workload Reports and 
Supporting Regulations Contained in 42 CFR 493.1-.2001.
    Form No.: CMS-102 and CMS-105.
    OMB #: 0938-0599.
    Use: Information collected will be used by CMS in determining the 
amount of Federal Reimbursement for compliance surveys. Use of the 
information includes program evaluation, audit, budget formulation, and 
budget approval.
    Frequency: Quarterly and Annually.
    Affected Public: State, Local, or Tribal Government.
    Number of Respondents: 50.
    Total Annual Responses: 50.
    Total Annual Hours: 4,500.
    3. Type of Information Collection Request: Extension of a currently 
approved collection.
    Title of Information Collection: Application for Hospital Insurance 
and Supporting Regulations in 42 CFR 406.7.
    Form No.: CMS-18F5.
    OMB #: 0938-0251.
    Use: The CMS-18F5 is used to establish entitlement to Hospital 
Insurance and Supplementary Medical Insurance for beneficiaries 
entitled under Title XVIII of the Social Security Act. The HCFA-18F5-SP 
is included in this renewal. (The Agency name change on the Spanish 
language form has not been done because there is still stock on hand.)
    Frequency: On occasion.
    Affected Public: Individuals or Households, Business or other for-
profit, Not-for-profit institutions, Farms, Federal government, and 
State, local, or tribal gov.
    Number or Respondents: 50,000.
    Total Annual Responses: 50,000.
    Total Annual Hours: 12,500.
    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://www.cms.hhs.gov/regulations/pra/, 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 at (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: Christopher Martin, New 
Executive Office Building, Room 10235, Washington, DC 20503.

    Dated: August 6, 2004.
John P. Burke, III,
Paperwork Reduction Act Team Leader, CMS Reports Clearance Officer, 
Office of Strategic Operations and Regulatory Affairs, Division of 
Regulations Development and Issuances.
[FR Doc. 04-18619 Filed 8-19-04; 8:45 am]
BILLING CODE 4120-03-P