Federal Register / Vol. 69, No. 214 / Friday, November 5, 2004 / Notices 64575

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare and Medicaid 

Services 

[Document Identifier: CMS–10120] 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request

AGENCY: Centers for Medicare and 

Medicaid Services. 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: New Collection; Title of 

Information Collection: 1932 State Plan 

Amendment Template, State Plan 

Requirements and Supporting 

Regulations in 42 CFR 438.50; Form 

No.: CMS–10120 (OMB#0938–NEW); 

Use: The State Medicaid Agencies will 

complete the template. CMS will review 

the information to determine if the State 

has met all the requirements under 

1932(1)(1)(A) and 42 CFR 438.50. Once 

all requirements are met, the State will 

be allowed to enroll Medicaid 

beneficiaries on a mandatory basis into 

managed care entities without section 

1115 or 1915(b) waiver authority.; 

Frequency: On occasion; Affected 

Public: State, local, or tribal 

government; Number of Respondents:

56; Total Annual Responses: 10; Total 

Annual Hours: 100. 

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 Paperwork@hcfa.gov, 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: October 28, 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. 04–24780 Filed 11–4–04; 8:45 am] 

BILLING CODE 4120–03–M

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicine and Medicaid 

Services 

[Document Identifier: CMS–R–306 and 

CMS–R–148] 

Agency Information Collection 

Activities: Proposed Collection; 

Comment Request 

Agency: Centers for Medicare and 

Medicaid Services. 

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: Restraint and 

Seclusion Standards for Psychiatric 

Residential Treatment Facilities; Use:

Psychiatric residential treatment 

facilities are required to report deaths, 

serious injuries and attempted suicides 

to State Medicaid Agency and 

Protection and Advocacy Organization. 

They are also required to provide 

residents restraint and seclusion policy 

in writing, and to document resident 

record of all activities involving use of 

restraint and seclusion. Form Number:

CMS–R–306 (OMB#: 0938–0833); 

Frequency: On occasion; Affected 

Public: Business or other for-profit and 

Not-for-profit institutions; Number of 

Respondents: 500; Total Annual 

Responses: 2,600,000; Total Annual 

Hours: 877,750. 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Limitations on 

Provider Related Donations and Health 

Care Related Taxes; Limitation on 

payments to Disproportionate Share 

Hospitals; Medicaid and Supporting 

Regulations in 42 CFR 433.68, 433.74, 

and 447.272.; Use: This information 

collection is necessary to ensure 

compliance with Sections 1903 and 

1923 of the Social Security Act for the 

purpose of preventing payment of 

federal financial participation on 

amounts prohibited by the statute. Form 

Number: CMS–R–148 (OMB#: 0938–

0618); Frequency: Quarterly; Affected 

Public: State, Local or Tribal Gov’t; 

Number of Respondents: 50; Total 

Annual Responses: 40; Total Annual 

Hours: 3,200. 

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 Paperwork@cms.hhs.gov, 

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: October 28, 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. 04–24781 Filed 11–4–04; 8:45 am] 

BILLING CODE 4120–03–M