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

###### Centers for Medicare and Medicaid Services

          - [Document Identifier: CMS-10428]

# AGENCY:

Centers for Medicare and 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 and 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 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.

We are, however, requesting an emergency review of the information collection referenced below. In compliance with the requirement of section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995, we have submitted to the Office of Management and Budget (OMB) the following requirements for emergency review. We are requesting an emergency review to ensure compliance with section 1862(a)(1)(A) of the Social Security Act. We cannot reasonably comply with the normal clearance procedures in that public harm is reasonably likely to result if normal clearance procedures are followed as stated in 5 CFR 1320.13(a)(2)(i).

                        1.                         *Type of Information Collection Request:*                         New collection;                         *Title of Information Collection:*                         Pre-Existing Condition Insurance Plan (PCIP) HIPAA Authorization Form;                         *Use:*                         Unless permitted or required by law, the Health Insurance Portability and Accountability Act (HIPAA) privacy regulation at 45 CFR 164.508 prohibits CMS' Pre-Existing Condition Insurance Plan (PCIP) program (a HIPAA covered entity) from disclosing an individual's protected health information without a                               ( print page 14808)                            valid authorization. In order to be valid, an authorization must include specified core elements and statements. CMS will make available to PCIP applicants and enrollees a standard, valid authorization to enable beneficiaries to request the disclosure of their protected health information. CMS will make available to PCIP applicants and enrollees a standard, valid authorization to enable beneficiaries to communicate with PCIP about their personal health information. This is a critical tool because the population the PCIP program serves is comprised of individuals with pre-existing conditions who may be incapacitated and need an advocate to help them apply for or receive benefits from the program. This standard authorization will simplify the process of requesting information disclosure for beneficiaries and minimize the response time for the PCIP program;                         *Form Number:*                         CMS-10428 (OMB 0938-New);                         *Frequency:*                         Occasionally;                         *Affected Public:*                         Private Sector (Business or other for-profit and Not-for-profit institutions);                         *Number of Respondents:*                         2,100;                         *Total Annual Responses:*                         2,100;                         *Total Annual Hours:*                         525. (For policy questions regarding this collection contact Laura Dash at 410-786-8623. For all other issues call 410-786-1326.)                    

CMS is requesting OMB review and approval of this collection by March 22, 2012. To be assured consideration, comments and recommendations for the proposed information collections must be received by via one of the methods below on March 19, 2012.

                        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.gov/​PaperworkReductionActof1995/​PRAL/​list.asp*                         or Email 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.                    

Interested persons are invited to send comments regarding the burden or any other aspect of these collections of information requirements. However, as noted above, comments on these information collection and recordkeeping requirements must be received via one of the following methods by March 19, 2012.

                        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 CMS-10417, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.                    

                    3.                     *By Email to OMB.*                     OMB, Office of Information and Regulatory Affairs,                     *Attention:*                     CMS Desk Officer,                     *Email:**OIRA_submission@omb.eop.gov*.                

Dated: March 8, 2012.

Martique Jones,

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

[FR Doc. 2012-6035 Filed 3-12-12; 8:45 am]

BILLING CODE 4120-01-P