[Federal Register Volume 72, Number 225 (Friday, November 23, 2007)]
[Notices]
[Pages 65741-65744]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E7-22817]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Report of a Modified or Altered System of 
Records

AGENCY: Department of Health and Human Services (HHS), Centers for 
Medicare & Medicaid Services (CMS).

ACTION: Notice of a Modified or Altered System of Records (SOR).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to modify or alter an SOR, ``Employee Building 
Pass File (EBP) System, System No. 09-70-3002,'' last published at 67 
FR 40937 (June 14, 2002). We propose to assign a new CMS identification 
number to this system to simplify the obsolete and confusing numbering 
system originally designed to identify the Bureau, Office, or Center 
that maintained information in the Health Care Financing Administration 
systems of records. The new assigned identifying number for this system 
should read: System No. 09-70-0529.
    We propose to modify existing routine use number 2 that permits 
disclosure to agency contractors and consultants to include disclosure 
to CMS grantees who perform a task for the agency. CMS grantees, 
charged with completing projects or activities that require CMS data to 
carry out that activity, are classified separately from CMS contractors 
and/or consultants. The modified routine use will remain as routine use 
number 1. We will delete routine use number 3 authorizing disclosure to 
support constituent requests made to a congressional representative. If 
an authorization for the disclosure has been obtained from the data 
subject, then no routine use is needed. The Privacy Act allows for 
disclosures with the ``prior written consent'' of the data subject.
    Finally, we will delete the section titled ``Additional 
Circumstances Affecting Routine Use Disclosures,'' that addresses 
``Protected Health Information (PHI)'' and ``small cell size.'' The 
requirement for compliance with HHS regulation ``Standards for Privacy 
of Individually Identifiable Health Information'' does not apply 
because this system does not collect or maintain PHI. In addition, our 
policy to prohibit release if there is a possibility that an individual 
can be identified through ``small cell size'' is not applicable to the 
data maintained in this system.
    We are modifying the language in the remaining routine uses to 
provide a proper explanation as to the need for the routine use and to 
provide clarity to CMS's intention to disclose individual-specific 
information contained in this system. The routine uses will then be 
prioritized and reordered according to their usage. We will also take 
the opportunity to update any sections of the system that were affected 
by the recent reorganization or because of the impact of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) 
(Pub. L. 108-173) provisions and to update language in the 
administrative sections to correspond with language used in other CMS 
SORs.
    The primary purpose of the SOR is to issue and control United 
States Government building passes issued to all CMS employees and non-
CMS employees who require continuous access to CMS buildings in 
Baltimore and other CMS and HHS facilities. Information retrieved from 
this SOR will be used to: (1) Support regulatory and policy functions 
performed within the Agency or by a contractor, consultant, or grantee; 
(2) assist other Federal agencies with activities related to this 
system; and (3) support litigation

[[Page 65742]]

involving the Agency. We have provided background information about the 
modified system in the Supplementary Information section below. 
Although the Privacy Act requires only that CMS provide an opportunity 
for interested persons to comment on the proposed routine uses, CMS 
invites comments on all portions of this notice. See Effective Dates 
section for comment period.

DATES: Effective Dates: CMS filed a modified system report with the 
Chair of the House Committee on Government Reform and Oversight, the 
Chair of the Senate Committee on Homeland Security and Governmental 
Affairs, and the Administrator, Office of Information and Regulatory 
Affairs, Office of Management and Budget (OMB) on November 15, 2007. To 
ensure that all parties have adequate time in which to comment, the 
modified SOR, including routine uses, will become effective 40 days 
from the publication of the notice, or from the date it was submitted 
to OMB and the Congress, whichever is later, unless CMS receives 
comments that require alterations to this notice.

ADDRESSES: The public should address comments to: CMS Privacy Officer, 
Division of Privacy Compliance, Enterprise Architecture and Strategy 
Group, Office of Information Services, CMS, Room N2-04-27, 7500 
Security Boulevard, Baltimore, Maryland 21244-1850. Comments received 
will be available for review at this location, by appointment, during 
regular business hours, Monday through Friday from 9 a.m.-3 p.m., 
Eastern Time zone.

FOR FURTHER INFORMATION CONTACT: Marcia Levin, Security System 
Administrator, Emergency Management and Response Group, Office of 
Operations Management, CMS, Room SLL-11-28, 7500 Security Boulevard, 
Baltimore, Maryland 21244-1850. Ms. Levin can be reached by telephone 
at 410-786-7840, or via e-mail at [email protected].

SUPPLEMENTARY INFORMATION: 

I. Description of the Modified or Altered System of Records

A. Statutory and Regulatory Basis for SOR

    Authority for maintenance of this system of records is given under 
Section 5 United States Code (U.S.C.) 301, 40 USCA 121(c)(2), and 41 
Code of Federal Regulations (CFR) 102-74.375.

B. Collection and Maintenance of Data in the System

    The system contains information on Federal employees, contractors, 
consultants or grantees, Government Services Administration employees, 
and contract guards working in CMS's central office complex in 
Baltimore, Maryland, and other CMS and HHS Federal buildings. The 
system contains the name of the employee or other authorized 
individuals, social security number, identification card number, 
building/work location, phone number, position, title, grade, 
supervisor's name and telephone number.

II. Agency Policies, Procedures, and Restrictions on Routine Uses

    A. The Privacy Act permits us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such disclosure of data is known as a ``routine use.'' 
The government will only release EBP information that can be associated 
with an individual as provided for under ``Section III. Proposed 
Routine Use Disclosures of Data in the System. `` Both identifiable and 
non-identifiable data may be disclosed under a routine use.
    We will only disclose the minimum personal data necessary to 
achieve the purpose of EBP. CMS has the following policies and 
procedures concerning disclosures of information that will be 
maintained in the system. Disclosure of information from the SOR will 
be approved only to the extent necessary to accomplish the purpose of 
the disclosure and only after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason data is being collected; e.g., to issue and control United 
States Government building passes issued to all CMS employees and non-
CMS employees who require continuous access to CMS buildings in 
Baltimore and other CMS and HHS facilities.
    2. Determines that:
    a. The purpose for which the disclosure is to be made can only be 
accomplished if the record is provided in individually identifiable 
form;
    b. The purpose for which the disclosure is to be made is of 
sufficient importance to warrant the effect and/or risk on the privacy 
of the individual that additional exposure of the record might bring; 
and
    c. There is a strong probability that the proposed use of the data 
would in fact accomplish the stated purpose(s).
    3. Requires the information recipient to:
    a. Establish administrative, technical, and physical safeguards to 
prevent unauthorized use of disclosure of the record;
    b. Remove or destroy at the earliest time all patient-identifiable 
information; and
    c. Agree to not use or disclose the information for any purpose 
other than the stated purpose under which the information was 
disclosed.
    4. Determines that the data are valid and reliable.

III. Proposed Routine Use Disclosures of Data in the System

A. Entities Who May Receive Disclosures Under Routine Use

    These routine uses specify circumstances, in addition to those 
provided by statute in the Privacy Act of 1974, under which CMS may 
release information from the EBP without the consent of the individual 
to whom such information pertains. Each proposed disclosure of 
information under these routine uses will be evaluated to ensure that 
the disclosure is legally permissible, including but not limited to 
ensuring that the purpose of the disclosure is compatible with the 
purpose for which the information was collected. We are proposing to 
establish or modify the following routine use disclosures of 
information maintained in the system:
    1. To Agency contractors, consultants, or grantees who have been 
contracted by the Agency to assist in accomplishment of a CMS function 
relating to the purposes for this system and who need to have access to 
the records in order to assist CMS.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual or similar 
agreement with a third party to assist in accomplishing CMS functions 
relating to purposes for this system.
    CMS occasionally contracts out certain of its functions when this 
would contribute to effective and efficient operations. CMS must be 
able to give a contractor, consultants, or grantees whatever 
information is necessary for the contractor to fulfill its duties. In 
these situations, safeguards are provided in the contract prohibiting 
the contractor, consultants, or grantees from using or disclosing the 
information for any purpose other than that described in the contract 
and to return or destroy all information at the completion of the 
contract.
    2. To assist other Federal agencies with activities related to this 
system and who need to have access to the records in order to perform 
the activity.
    The Federal Protection Service may require EBP data to enable them 
to assist in inquiries about an individual's

[[Page 65743]]

authorization to enter CMS's central office complex in Baltimore, 
Maryland and other CMS and HHS Federal buildings.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual or similar 
agreement with another Federal agency to assist in accomplishing CMS 
functions relating to purposes for this SOR.
    3. To the Department of Justice (DOJ), court or adjudicatory body 
when
    a. the Agency or any component thereof; or
    b. any employee of the Agency in his or her official capacity; or
    c. any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee; or
    d. the United States Government;

is a party to litigation or has an interest in such litigation, and by 
careful review, CMS determines that the records are both relevant and 
necessary to the litigation and that the use of such records by the 
DOJ, court or adjudicatory body is compatible with the purpose for 
which the agency collected the records.
    Whenever CMS is involved in litigation, or occasionally when 
another party is involved in litigation and CMS's policies or 
operations could be affected by the outcome of the litigation, CMS 
would be able to disclose information to the DOJ, court or adjudicatory 
body involved. A determination would be made in each instance that, 
under the circumstances involved, the purposes served by the use of the 
information in the particular litigation is compatible with a purpose 
for which CMS collects the information.

IV. Safeguards

    CMS has safeguards in place for authorized users and monitors such 
users to ensure against unauthorized use. Personnel having access to 
the system have been trained in the Privacy Act and information 
security requirements. Employees who maintain records in this system 
are instructed not to release data until the intended recipient agrees 
to implement appropriate management, operational and technical 
safeguards sufficient to protect the confidentiality, integrity and 
availability of the information and information systems and to prevent 
unauthorized access.
    This system will conform to all applicable Federal laws and 
regulations and Federal, HHS, and CMS policies and standards as they 
relate to information security and data privacy. These laws and 
regulations include but are not limited to: the Privacy Act of 1974; 
the Federal Information Security Management Act of 2002; the Computer 
Fraud and Abuse Act of 1986; the Health Insurance Portability and 
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the 
corresponding implementing regulations. OMB Circular A-130, Management 
of Federal Resources, Appendix III, Security of Federal Automated 
Information Resources also applies. Federal, HHS, and CMS policies and 
standards include but are not limited to: All pertinent National 
Institute of Standards and Technology publications; HHS Information 
Systems Program Handbook and the CMS Information Security Handbook.

V. Effects of the Modified System of Records on Individual Rights

    CMS proposes to establish this system in accordance with the 
principles and requirements of the Privacy Act and will collect, use, 
and disseminate information only as prescribed therein. Data in this 
system will be subject to the authorized releases in accordance with 
the routine uses identified in this system of records.
    CMS will take precautionary measures to minimize the risks of 
unauthorized access to the records and the potential harm to individual 
privacy or other personal or property rights of patients whose data are 
maintained in the system. CMS will collect only that information 
necessary to perform the system's functions. In addition, CMS will make 
disclosure from the proposed system only with consent of the subject 
individual, or his/her legal representative, or in accordance with an 
applicable exception provision of the Privacy Act. CMS, therefore, does 
not anticipate an unfavorable effect on individual privacy as a result 
of the disclosure of information relating to individuals.

    Dated: November 7, 2007.
Charlene Frizzera,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
SYSTEM NO. 09-70-0529

SYSTEM NAME:
    ``Employee Building Pass File (EBPF),'' HHS/CMS/OOM.

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive Data.

SYSTEM LOCATION:
    The Centers for Medicare & Medicaid Services (CMS) Data Center, 
7500 Security Boulevard, North Building, First Floor, Baltimore, 
Maryland 21244-1850 and at various other contractor locations.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    The system contains information on Federal employees, contractors, 
consultants or grantees, Government Services Administration employees, 
and contract guards working in CMS's central office complex in 
Baltimore, Maryland, and other CMS and HHS Federal buildings.

CATEGORIES OF RECORDS IN THE SYSTEM:
    The system contains the name of the employee or other authorized 
individuals, social security number (SSN), identification card number, 
building/work location, phone number, position, title, grade, 
supervisor's name and telephone number.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Authority for maintenance of this system of records is given under 
Section 5 United States Code (U.S.C.) 301, 40 USCA 121(c)(2), and 41 
Code of Federal Register (CFR) 102-74.375.

PURPOSE(S) OF THE SYSTEM:
    The primary purpose of the SOR is to issue and control United 
States Government building passes issued to all CMS employees and non-
CMS employees who require continuous access to CMS buildings in 
Baltimore and other CMS and HHS facilities. Information retrieved from 
this SOR will be used to: (1) Support regulatory and policy functions 
performed within the Agency or by a contractor, consultant, or grantee; 
(2) assist other Federal agencies with activities related to this 
system; and (3) support litigation involving the Agency.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OR USERS AND THE PURPOSES OF SUCH USES:
    A. The Privacy Act allows us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such compatible use of data is known as a ``routine 
use.'' The proposed routine uses in this system meet the compatibility 
requirement of the Privacy Act. We are proposing to establish the 
following routine use disclosures of information maintained in the 
system:
    1. To Agency contractors, consultants, or grantees who have been 
contracted by the Agency to assist in accomplishment of a CMS function 
relating to the purposes for this system and who need

[[Page 65744]]

to have access to the records in order to assist CMS.
    2. To assist other Federal agencies with activities related to this 
system and who need to have access to the records in order to perform 
the activity.
    3. To the Department of Justice (DOJ), court or adjudicatory body 
when
    a. the Agency or any component thereof; or
    b. any employee of the Agency in his or her official capacity; or
    c. any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee; or
    d. the United States Government;

    is a party to litigation or has an interest in such litigation, and 
by careful review, CMS determines that the records are both relevant 
and necessary to the litigation and that the use of such records by the 
DOJ, court or adjudicatory body is compatible with the purpose for 
which the agency collected the records.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    All records are stored on electronic media.

RETRIEVABILITY:
    The collected data are retrieved by an individual identifier; e.g., 
name or SSN.

SAFEGUARDS:
    CMS has safeguards in place for authorized users and monitors such 
users to ensure against unauthorized use. Personnel having access to 
the system have been trained in the Privacy Act and information 
security requirements. Employees who maintain records in this system 
are instructed not to release data until the intended recipient agrees 
to implement appropriate management, operational and technical 
safeguards sufficient to protect the confidentiality, integrity and 
availability of the information and information systems and to prevent 
unauthorized access.
    This system will conform to all applicable Federal laws and 
regulations and Federal, HHS, and CMS policies and standards as they 
relate to information security and data privacy. These laws and 
regulations may apply but are not limited to: the Privacy Act of 1974; 
the Federal Information Security Management Act of 2002; the Computer 
Fraud and Abuse Act of 1986; the Health Insurance Portability and 
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the 
corresponding implementing regulations. OMB Circular A-130, Management 
of Federal Resources, Appendix III, Security of Federal Automated 
Information Resources, also applies. Federal, HHS, and CMS policies and 
standards include but are not limited to: All pertinent National 
Institute of Standards and Technology publications; the HHS Information 
Systems Program Handbook and the CMS Information Security Handbook.

RETENTION AND DISPOSAL:
    CMS will retain information for a total period not to exceed 25 
years. All claims-related records are encompassed by the document 
preservation order and will be retained until notification is received 
from DOJ.

SYSTEM MANAGER AND
    Director Security & Emergency Management Group, Office of 
Operations Management, CMS, Room SLL-11-28, 7500 Security Boulevard, 
Baltimore, Maryland 21244-1850.

NOTIFICATION PROCEDURE:
    For purpose of access, the subject individual should write to the 
system manager who will require the system name, employee 
identification number, tax identification number, national provider 
number, and for verification purposes, the subject individual's name 
(woman's maiden name, if applicable), HICN, and/or SSN (furnishing the 
SSN is voluntary, but it may make searching for a record easier and 
prevent delay).

RECORD ACCESS PROCEDURE:
    For purpose of access, use the same procedures outlined in 
Notification Procedures above. Requestors should also reasonably 
specify the record contents being sought. (These procedures are in 
accordance with Department regulation 45 CFR 5b.5(a)(2)).

CONTESTING RECORD PROCEDURES:
    The subject individual should contact the system manager named 
above, and reasonably identify the record and specify the information 
to be contested. State the corrective action sought and the reasons for 
the correction with supporting justification. (These procedures are in 
accordance with Department regulation 45 CFR 5b.7).

RECORDS SOURCE CATEGORIES:
    CMS obtains information in this system from the individuals who are 
covered by this system.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.

 [FR Doc. E7-22817 Filed 11-21-07; 8:45 am]
BILLING CODE 4120-03-P