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

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

          - [Document Identifier: CMS-116 and CMS-417] 

# 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), 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 function; (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:*                     Clinical Laboratory Improvement Amendments (CLIA) Application Form and Supporting Regulations in 42 CFR 493.1-.2001Medicare/Medicaid Psychiatric Hospital Survey Data;                     *Use:*                     The application must be completed by entities performing laboratory's testing specimens for diagnostic or treatment purposes. This information is vital to the certification process.                     *Form Number:*                     CMS-116 (OMB#: 0938-0581);                     *Frequency:*                     Biennially and Occasionally;                     *Affected Public:*                     Private Sector: Business or other for-profits and Not-for-profit institutions;                     *Number of Respondents:*                     219,000; Total                    *Annual Responses:*                     31,520;                     *Total Annual Hours:*                     23,640. (For policy questions regarding this collection contact Sheila Ward at 410-786-3115. For all other issues call 410-786-1326.)                 

                    2.                     *Type of Information Collection Request:*                     Extension of a currently approved collection;                     *Title of Information Collection:*                     Hospice Request for Certification in the Medicare Program;                     *Use:*                     The Hospice Request for Certification Form is the identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program.                     *Form Number:*                     CMS-417 (OMB#: 0938-0313);                     *Frequency:*                     Annually;                     *Affected Public:*                     Private Sector: Business or other for-profits;                     *Number of Respondents:*                     3,494; Total                    *Annual Responses:*                     3,494;                     *Total Annual Hours:*                     594. (For policy questions regarding this collection contact Debbie Terkay at 410-786-6835. 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 address 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 on (410) 786-1326.                 

                    To be assured consideration, comments and recommendations for the proposed information collections must be received by the OMB desk officer at the address below, no later than 5 p.m. on                     *December 27, 2010.*

OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk Officer, 

Fax Number: (202) 395-6974. 

                    E-mail:                     *OIRA_submission@omb.eop.gov.*

Dated: November 18, 2010. 

Michelle Shortt, 

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

[FR Doc. 2010-29718 Filed 11-24-10; 8:45 am] 

BILLING CODE 4120-01-P