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

###### Health Care Financing Administration 

          - [Document Identifier: HCFA-1763] 

# AGENCY:

Health Care Financing Administration, HHS. In compliance with the requirement of section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995, 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. 

*Type of Information Collection Request:*                         Extension of a currently approved collection;                    

*Title of Information Collection:*                         Request for Termination of Premium Hospital and/or Supplementary Medical Insurance and Supporting Regulations in 42 CFR 406.28 and 407.27;                    

*Form No.:*                         HCFA-1763 (OMB No. 0938-0025);                    

*Use:*                         The HCFA-1763 is used by beneficiaries to request voluntary termination from premium hospital and/or supplementary medical insurance.                     

*Frequency:*                         One time only;                    

*Affected Public:*                         Individuals or Households, Federal Government, and State, Local or Tribal Government;                    

*Number of Respondents:*                         14,000;                    

*Total Annual Responses:*                         14,000;                    

*Total Annual Hours:*                         5,833.                    

To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access HCFA's Web Site address at http://www.hcfa.gov/​regs/​prdact95.htm, or E-mail your request, including your address, phone number, OMB number, and HCFA 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 60 days of this notice directly to the HCFA Paperwork Clearance Officer designated at the following address: HCFA, Office of Information Services, Security and Standards Group, Division of HCFA Enterprise Standards, Attention: Dawn Willinghan, Room N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Dated: June 22, 2000.

John P. Burke III,

HCFA Reports Clearance Officer, HCFA Office of Information Services, Security and Standards Group, Division of HCFA Enterprise Standards.

[FR Doc. 00-16595 Filed 6-29-00; 8:45 am] 

BILLING CODE 4120-03-P