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[Federal Register Volume 76, Number 68 (Friday, April 8, 2011)]
[Notices]
[Pages 19776-19777]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-8462]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-10252, CMS-1856 and CMS-1893]

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: Revision of a currently 
approved collection; Title of Information Collection: Certificate of 
Destruction for Data Acquired from the Centers for Medicare and 
Medicaid Services; Use: The Certificate of Destruction is used by 
recipients of CMS data to certify that they have destroyed the data 
they have received through a CMS Data Use Agreement (DUA). The DUA 
requires the destruction of the data at the completion of the project/
expiration of the DUA. The DUA addresses the conditions under which CMS 
will disclose and the User will maintain CMS data that are protected by 
the Privacy Act of 1974, Sec.  552a and the Health Insurance 
Portability Accountability Act of 1996. CMS has developed policies and 
procedures for such disclosures that are based on the Privacy Act and 
the Health Insurance Portability Act (HIPAA). The Certificate of 
Destruction is required to close out the DUA and to ensure the data are 
destroyed and not used for another purpose. Form Number: CMS-10252 
(OMB 0938-1046); Frequency: On occasion; Affected Public: 
Business or other for-profit; Number of Respondents: 500; Total Annual 
Responses: 500; Total Annual Hours: 84. (For policy questions regarding 
this collection, contact Sharon Kavanagh at (410) 786-5441. For all 
other issues call (410) 786-1326.)
    2. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: (CMS-1856) 
Request for Certification in the Medicare and/or Medicaid Program to 
Provide Outpatient Physical Therapy and/or Speech Pathology Services, 
and (CMS-1893) Outpatient Physical Therapy--Speech Pathology Survey 
Report; Use: CMS-1856 is used as an application to be completed by 
providers of outpatient physical therapy and/or speech-

[[Page 19777]]

language pathology services requesting participation in Medicare/
Medicaid programs. This form initiates the process for obtaining a 
decision as to whether the conditions of participation are met as a 
provider of outpatient physical therapy and/or speech-language 
pathology services. It is used by the State agencies to enter new 
provider into the ASPEN (Automated Survey Process Environment). CMS-
1893 is used by the State survey agency to record data collected during 
an on-site survey of a provider of outpatient physical therapy and/or 
speech-language pathology services, to determine compliance with the 
applicable conditions of participation, and to report this information 
to the Federal Government. The form is primarily a coding worksheet 
designed to facilitate data reduction and retrieval into the ASPEN 
system. The information needed to make certification decisions is 
available to CMS only through the use of information abstracted from 
the form; Form Numbers: CMS-1856 and CMS-1893 (OMB: 0938-
0065); Frequency: Annually, occasionally; Affected Public: Private 
Sector; Business or other for-profit and not-for-profit institutions; 
Number of Respondents: 2,968; Total Annual Responses: 495; Total Annual 
Hours: 866. (For policy questions regarding this collection contact 
Georgia Johnson at 410-786-6859. 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 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 at 410-786-1326.
    In commenting on the proposed information collections please 
reference the document identifier or OMB control number. To be assured 
consideration, comments and recommendations must be submitted in one of 
the following ways by June 7, 2011.
    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: April 1, 2011.
Michelle Shortt,
Director, Regulations Development Group, Office of Strategic Operations 
and Regulatory Affairs.
[FR Doc. 2011-8462 Filed 4-7-11; 8:45 am]
BILLING CODE 4120-01-P
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