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[Federal Register Volume 76, Number 195 (Friday, October 7, 2011)]
[Notices]
[Pages 62413-62414]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-26034]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-10268 and CMS-1696]

Agency Information Collection Activities: Proposed Collection; 
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) 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 a currently 
approved collection; Title of Information Collection: Consolidated 
Renal Operations in a Web Enabled Network (CROWNWeb) Third-party 
Submission Authorization Form; Use: The Consolidated Renal Operations 
in a Web Enabled Network (CROWNWeb) Third-Party Submission 
Authorization form is to be completed by ``Facility Administrators'' 
(administrators of CMS-certified dialysis facilities) if they intend to 
authorize a third party (a business with which the facility is 
associated, or an independent vendor) to submit data to CMS to comply 
with the recently-revised Conditions for Coverage of dialysis 
facilities. The CROWNWeb system is the system used as the collection 
point of data necessary for entitlement of ESRD patients to Medicare 
benefits and for Federal Government monitoring and assessing of the 
quality and types of care provided to renal patients. The information 
collected through the CWTPSA form will allow CMS and its contractors to 
receive data from authorized parties acting on behalf of CMS-certified 
dialysis facilities. Since February 2009, CMS has received 4,160 CWTPSA 
forms and anticipates that they will continue to receive no more than 
400 new CWTPSA forms annually to address the creation of new facilities 
under the current participating ``third party submitters.'' Form 
Number: CMS-10268 (OCN: 0938-1052); Frequency: Occasionally; Affected 
Public: Private Sector; Business or other for-profits and Not-for-
profit institutions; Number of Respondents: 400; Total Annual 
Responses: 400; Total Annual Hours: 34. (For policy questions regarding 
this collection contact Michelle Tucker at 410-786-0736. For all other 
issues call 410-786-1326.)
    2. 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 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

[[Page 62414]]

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 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.
    In commenting on the proposed information collections please 
reference the document identifier or OMB control number. To be assured 
consideration, comments must be received by December 6, 2011, and 
submitted in one of the following ways:
    1. Electronically. You may submit your comments electronically to 
http://www.regulations.gov. Follow the instructions for ``Comment or 
Submission'' or ``More Search Options'' to find the information 
collection document(s) accepting comments.
    2. By regular mail. You may mail written comments to the following 
address: CMS, Office of Strategic Operations and Regulatory Affairs, 
Division of Regulations Development, Attention: Document Identifier/OMB 
Control Number, Room C4-26-05, 7500 Security Boulevard, Baltimore, 
Maryland 21244-1850.

    Dated: October 4, 2011.
Martique Jones,
Director, Regulations Development Group, Division B, Office of 
Strategic Operations and Regulatory Affairs.
[FR Doc. 2011-26034 Filed 10-6-11; 8:45 am]
BILLING CODE 4120-01-P
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