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

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

          - [Document Identifier: CMS-10176] 

# 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:*                     New Collection;                     *Title of Information Collection:*                     Governmental Status of Health Care Provider Form;                     *Use:*                     The questions presented on the “Governmental Status of Health Care Provider” form are required for CMS to be able to determine the permissibility of State funding sources associated with selected reimbursement-related State Plan Amendments. Without the information gathered on this form, CMS will not be able to determine the State's compliance with Section 1902(a)(30)(A) or Section 1903(w) of the Social Security Act. If CMS cannot determine compliance, CMS cannot approve the State Plan Amendments, resulting in potential harm to Medicaid beneficiaries. The respondents of this information request will be the State's State Medicaid Agency.                     *Form Number:*                     CMS-10176 (OMB#: 0938-NEW);                     *Frequency:*                     Reporting: Once and on occasion;                     *Affected Public:*                     State, Local, or Tribal Governments;                     *Number of Respondents:*                     50;                     *Total Annual Responses:*                     4,000;                     *Total Annual Hours:*                     4,000.                 

                    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 at the address below, no later than 5 p.m. on March 20, 2007. 
      ( print page 2533)    
CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development—A, Attention: Melissa Musotto, Room C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850. 

Dated: January 12, 2007. 

Michelle Shortt, 

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

 [FR Doc. E7-700 Filed 1-18-07; 8:45 am] 

BILLING CODE 4120-01-P