Document Headings

                    Document headings vary by document type but may contain                    the following:                  
                -                       the agency or agencies that issued and signed a document                    
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###### Department of Health and Human Services

###### Centers for Medicare and Medicaid Services

          - [Document Identifier: CMS-10052 and CMS-370, 377, 378, R-54]

# 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 currently approved collection;                         *Title of Information Collection:*                         Recognition of Pass-Through Payment for Additional (new) Categories of Devices under the Outpatient Prospective Payment System and Supporting Regulations in 42 CFR part 419;                         *Use:*                         Information is necessary to determine eligibility of medical devices for establishment of additional device categories for payment under                               ( print page 67745)                            transitional pass-through payment provisions as required by section 1833(t)(6) of the Social Security Act.                         *Form Number:*                         CMS-10052 (OMB#: 0938-0857);                         *Frequency:*                         On occasion;                         *Affected Public:*                         Business or other for-profit;                         *Number of Respondents:*                         12; Total                        *Annual Responses:*                         12; Total                         *Annual Hours:*                         192.                    

                        2.                         *Type of Information Collection Request:*                         Revision of currently approved collection;                         *Title of Information Collection:*                         Ambulatory Surgical Center (ASC) Health Insurance Benefit Agreement, ASC Request for Certification, ASC Survey Report and Supporting Regulations in 42 CFR 416.41, 416.43, 416.47, and 416.48;                         *Use:*                         The ASC Health Insurance Benefits Agreement form is utilized for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act. The ASC Request for Certification form is utilized as an application for facilities wishing to participate in the Medicare program as an ASC. This form initiates the process of obtaining a decision as to whether the conditions of coverage are met. It also promotes data retrieval from the Online Data Input Edit (ODIE system, a subsystem of the Online Survey Certification and Report (OSCAR) system by the Centers for Medicare and Medicaid Services (CMS) Regional Offices (RO)). The ASC Report Form is an instrument used by the State survey agency to record data collection in order to determine supplier compliance with individual conditions of coverage and to report it to the Federal government. The form is primarily a coding worksheet designed to facilitate data reduction and retrieval into the ODIE/OSCAR system at the CMS ROs. This form includes basic information on compliance (                        *i.e.*, met, not met and explanatory statements) and does not require any descriptive information regarding the survey activity itself;                         *Form Number:*                         CMS-370, 377, 378, R-54 (OMB#: 0938-0266);                         *Frequency:*                         Annually and Other: once;                         *Affected Public:*                         State, Local or Tribal Government;                         *Number of Respondents:*                         4,312; Total                         *Annual Responses:*                         4,312; Total                         *Annual Hours:*                         2,241.                    

                        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 on (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: November 10, 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. 04-25720 Filed 11-18-04; 8:45 am]

BILLING CODE 4120-03-P