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

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

          - [Document Identifier CMS-10287]

# 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:*                     New collection;                     *Title of Information Collection:*                     Medicare Quality of Care Complaint Form;                     *Use:*                     In accordance with section 1154(a)(14) of the Social Security Act, Quality Improvement Organizations (QIOs) are required to conduct appropriate reviews of all written complaints submitted by beneficiaries concerning the quality of care received. The Medicare Quality of Care Complaint Form will be used by Medicare beneficiaries to submit quality of care complaints. This form will establish a standard form for all beneficiaries to utilize and ensure pertinent information is obtained by QIOs to effectively process these complaints.                     *Form Number:*                     CMS-10287 (OMB#: 0938-New);                     *Frequency:*                     Reporting—On occasion;                     *Affected Public:*                     Individuals or Households;                     *Number of Respondents:*                     3,500;                     *Total Annual Responses:*                     3,500;                     *Total Annual Hours:*                     583. (For policy questions regarding this collection contact Tom Kessler at 410-786-1991. 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 November 9, 2009                    *.*

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

Dated: October 1, 2009.

Michelle Shortt,

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

[FR Doc. E9-24233 Filed 10-8-09; 8:45 am]

BILLING CODE 4120-01-P