Document Headings

                    Document headings vary by document type but may contain                    the following:                  
                -                       the agency or agencies that issued and signed a document                    
                -                       the number of the CFR title and the number of each part                      the document amends, proposes to amend, or is directly                      related to                    
                -                       the agency docket number / agency internal file number                    
                -                       the RIN which identifies each regulatory action listed in                      the Unified Agenda of Federal Regulatory and Deregulatory                      Actions                    

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###### Department of Health and Human Services

###### Centers for Medicare & Medicaid Services

          - [Document Identifier: CMS-10252, CMS-1856 and CMS-1893]

# 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) 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:*                     Certificate of Destruction for Data Acquired from the Centers for Medicare and Medicaid Services;                     *Use:*                     The Certificate of Destruction is used by recipients of CMS data to certify that they have destroyed the data they have received through a CMS Data Use Agreement (DUA). The DUA requires the destruction of the data at the completion of the project/expiration of the DUA. The DUA addresses the conditions under which CMS will disclose and the User will maintain CMS data that are protected by the Privacy Act of 1974, § 552a and the Health Insurance Portability Accountability Act of 1996. CMS has developed policies and procedures for such disclosures that are based on the Privacy Act and the Health Insurance Portability Act (HIPAA). The Certificate of Destruction is required to close out the DUA and to ensure the data are destroyed and not used for another purpose.                     *Form Number:*                     CMS-10252 (OMB# 0938-1046);                     *Frequency:*                     On occasion;                     *Affected Public:*                     Business or other for-profit;                     *Number of Respondents:*                     500;                     *Total Annual Responses:*                     500;                     *Total Annual Hours:*                     84. (For policy questions regarding this collection, contact Sharon Kavanagh at (410) 786-5441. For all other issues call (410) 786-1326.)                

                    2.                     *Type of Information Collection Request:*                     Extension of a currently approved collection;                     *Title of Information Collection:*                     (CMS-1856) Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services, and (CMS-1893) Outpatient Physical Therapy—Speech Pathology Survey Report;                     *Use:*                     CMS-1856 is used as an application to be completed by providers of outpatient physical therapy and/or speech-                          ( print page 19777)                        language pathology services requesting participation in Medicare/Medicaid programs. This form initiates the process for obtaining a decision as to whether the conditions of participation are met as a provider of outpatient physical therapy and/or speech-language pathology services. It is used by the State agencies to enter new provider into the ASPEN (Automated Survey Process Environment). CMS-1893 is used by the State survey agency to record data collected during an on-site survey of a provider of outpatient physical therapy and/or speech-language pathology services, to determine compliance with the applicable conditions of participation, and to report this information to the Federal Government. The form is primarily a coding worksheet designed to facilitate data reduction and retrieval into the ASPEN system. The information needed to make certification decisions is available to CMS only through the use of information abstracted from the form;                     *Form Numbers:*                     CMS-1856 and CMS-1893 (OMB#: 0938-0065);                     *Frequency:*                     Annually, occasionally;                     *Affected Public:*                     Private Sector; Business or other for-profit and not-for-profit institutions;                     *Number of Respondents:*                     2,968;                     *Total Annual Response*                    s: 495;                     *Total Annual Hours:*                     866. (For policy questions regarding this collection contact Georgia Johnson at 410-786-6859. For all other issues call 410-786-1326.)                

                    To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access CMS' Web site at                     *http://www.cms.hhs.gov/​PaperworkReductionActof1995,*                     or e-mail your request, including your address, phone number, OMB number, and CMS document identifier, to                     *Paperwork@cms.hhs.gov,*                     or call the Reports Clearance Office at 410-786-1326.                

In commenting on the proposed information collections please reference the document identifier or OMB control number. To be assured consideration, comments and recommendations must be submitted in one of the following ways by June 7, 2011.

                    1.                     *Electronically.*                     You may submit your comments electronically to                     *http://www.regulations.gov.*                     Follow the instructions for “Comment or Submission” or “More Search Options” to find the information collection document(s) accepting comments.                

                    2.                     *By regular mail.*                     You may mail written comments to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier/OMB Control Number, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.                

Dated: April 1, 2011.

Michelle Shortt,

Director, Regulations Development Group, Office of Strategic Operations and Regulatory Affairs.

[FR Doc. 2011-8462 Filed 4-7-11; 8:45 am]

BILLING CODE 4120-01-P