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[Federal Register Volume 77, Number 15 (Tuesday, January 24, 2012)]
[Notices]
[Pages 3477-3478]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-1361]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-1696]

Agency Information Collection Activities: Submission for OMB 
Review; Comment Request

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: Extension of a currently 
approved collection; Title of Information Collection: Appointment of 
Representative; Use: This information collection requests re-approval 
of an information collection associated with regulations that permit 
individuals or entities to appoint representatives to exercise their 
rights to appeal an initial determination. The Appointment of 
Representative form will be completed by beneficiaries, providers and 
suppliers who wish to appoint representatives to assist them with 
obtaining initial determinations and filing appeals. The appointment of 
representative form must be signed by the party making the appointment 
and

[[Page 3478]]

the individual agreeing to accept the appointment. Form Number: CMS-
1696 (OCN: 0938-0950); Frequency: Occasionally; Affected Public: 
Individuals or households and Business or other for-profits; Number of 
Respondents: 265,481; Total Annual Responses: 265,481; Total Annual 
Hours: 66,370. (For policy questions regarding this collection contact 
Katherine Hosna at (410) 786-4993. 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 
Email 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 February 23, 
2012.

    OMB, Office of Information and Regulatory Affairs, Attention: CMS 
Desk Officer, Fax Number: (202) 395-6974, Email: OIRA_submission@omb.eop.gov.

    Dated: January 18, 2012.
Martique Jones,
Director, Regulations Development Group, Division-B, Office of 
Strategic Operations and Regulatory Affairs.
[FR Doc. 2012-1361 Filed 1-23-12; 8:45 am]
BILLING CODE 4120-01-P
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