### 9579 Federal Register/ Vol. 76, No. 34 / Friday, February 18, 2011 / Notices

Place: DoubleTree Hotel Atlanta Buckhead, 3342 Peachtree Road, NE., Piedmont Room, Atlanta, Georgia

30326.

Contact Person for Additional Information: Nancy Anderson, Chief, Laboratory Practice Standards Branch, Division of Laboratory Science and Standards, Laboratory Science, Policy and Practice Program Office, Office of Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, 1600 Clifton Road, NE., Mailstop F–11, Atlanta, Georgia 30333; telephone (404) 498– 2741; fax (404) 498–2219; or via e-mail

at Nancy.Anderson@cdc.hhs.gov

.

The Director, Management Analysis and Services Office, has been delegated the authority to sign Federal Register Notices pertaining to announcements of meetings and other committee management activities, for the Centers
for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry.

Dated: February 14, 2011.
Elaine L. Baker, Director, Management Analysis and Services Office, Centers for Disease Control and

Prevention.

[FR Doc. 2011–3707 Filed 2–17–11; 8:45 am]

**BILLING CODE 4163–18–P**

**DEPARTMENT OF HEALTH AND**
**HUMAN SERVICES**

**Centers for Medicare & Medicaid**
**Services**

**[Document Identifier: CMS–10251]**

**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: Integrated
Medicare and Medicaid State Plan Preprint; Form No.: CMS–10251 (OMB#: 0938–1047); Use: The Integrated Care Preprint is an optional tool for use by States to highlight the arrangements provided between the State and Medicare Advantage Special Needs Plans that are also providing Medicaid services. The preprint also provides the opportunity for States to confirm that their integrated care model complies with Federal statutory and regulatory requirements. State Medicaid Agencies may complete the preprint and CMS will review the information provided to determine if the State has properly completed and explained their integrated care arrangements and that the appropriate assurances have been

met; Frequency: Once;Affected Public: State, Local, or Tribal Governments; Number of Respondents: 56; Total Annual Responses: 10; Total Annual

Hours: 200. (For policy questions regarding this collection contact Mary
Pat Farkas at 410–786–5731. 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 April 19, 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.

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

[FR Doc. 2011–3749 Filed 2–17–11; 8:45 am]

**BILLING CODE 4120–01–P**

**DEPARTMENT OF HEALTH AND**
**HUMAN SERVICES**

**Centers for Medicare & Medicaid**
**Services**

**[Document Identifier: CMS–21 and –21B, CMS–37, CMS–64, CMS–10098, CMS–10106,**  **CMS–10120, CMS–10292, and CMS–10220]**

**Agency Information Collection**
**Activities: Submission for OMB Review; 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), 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 function; (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: CMS–21 (Quarterly Children’s Health Insurance Program (CHIP) Statement of Expenditures for the Title XXI Program) and CMS–21B (State Children’s Health Insurance Program Budget Report for the Title XXI Program State Plan Expenditures); Use: Forms CMS–21 and –21B provide CMS with the information necessary to issue quarterly grant awards, monitor current year expenditure levels, determine the allowability of State claims for reimbursement, develop CHIP financial management information, provide for State reporting of waiver expenditures, and ensure that the Federally


### 9580 Federal Register/ Vol. 76, No. 34 / Friday, February 18, 2011 / Notices

established allotment is not exceeded. Further, these forms are necessary in the
redistribution and reallocation of unspent funds over the Federally mandated timeframes; Form Numbers: CMS–21 and CMS–21B (OMB#: 0938– 0731); Frequency: Quarterly;Affected
Public: State, Local, or Tribal Governments; Number of Respondents:

56; Total Annual Responses: 448; Total
Annual Hours: 7,840. (For policy questions regarding this collection contact Jonas Eberly at 410–786–6232. For all other issues call 410–786–1326.)

2. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Medicaid Program Budget Report; Use: Form CMS–37 is prepared and submitted to
the Centers for Medicare & Medicaid Services (CMS) by State Medicaid agencies. Form CMS–37 is the primary document used by CMS in developing the national Medicaid budget estimates
that are submitted to the Office of Management and Budget and the Congress; Form Number: CMS–37 (OMB#: 0938–0101); Frequency: Quarterly;Affected Public: State, Local, or Tribal Governments; Number of Respondents: 56; Total Annual Responses: 224; Total Annual Hours: 7,616. (For policy questions regarding this collection contact Jonas Eberly at
410–786–6232. For all other issues call 410–786–1326.)

3. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program; Use: Form CMS–64 has been used since January 1980 by the Medicaid State Agencies to report their actual program
benefit costs and administrative expenses to CMS. CMS uses this information to compute the Federal financial participation for the State’s Medicaid Program costs. Certain
schedules of the CMS–64 form are used by States to report budget, expenditure
and related statistical information required for implementation of the Medicaid portion of the State Children’s Health Insurance Programs; Form Number: CMS–64 (OMB#: 0938–0067); Frequency: Quarterly;Affected Public: State, Local, or Tribal Governments; Number of Respondents: 56; Total Annual Responses: 224; Total Annual

Hours: 16,464. (For policy questions regarding this collection contact Jonas Eberly at 410–786–6232. For all other issues call 410–786–1326.)

4. Type of Information Collection Request: Reinstatement with change of a previously approved collection; Title of Information Collection: Beneficiary Satisfaction Survey; Use: The Beneficiary Satisfaction survey is performed to insure that the CMS 1–800–MEDICARE Helpline contractor is delivering satisfactory service to the Medicare beneficiaries. It gathers data on several Helpline operations such as print fulfillment and Web sites tool
hosted on http://www.medicare.gov. Respondents to the survey are Medicare
beneficiaries that have contacted 1–800–
MEDICARE for information on benefits and services. CMS is seeking approval for additional questions to be added to the original collection entitled 800– Medicare Beneficiary Satisfaction survey. The original set of questions was used when placing outbound calls to callers regarding the service they received when they called the 800 Medicare Helpline with a Medicare question. The new expanded collection will include multiple survey methods to measure customer satisfaction not only with the Beneficiary Contact Center’s (BCC’s) handling of issues via telephone, but also the service provided to beneficiaries when they write a letter regarding their Medicare issue or use
the e-mail and/or Web chat services provided by the BCC. The use of Customer Satisfaction Surveys is critical to the CMS mission to provide service to beneficiaries that is convenient, accessible, accurate, courteous, professional and responsive to the needs of diverse groups. Form Number: CMS– 10098 (OMB#: 0938–0919); Frequency: Weekly, Monthly, and Yearly; Affected
Public: Individuals and Households; Number of Respondents: 36,144; Total Annual Responses: 36,144; Total
Annual Hours: 6,033. (For policy questions regarding this collection
contact Mark Broccolino at 410–786–
6128. For all other issues call 410–786– 1326.)

5. Type of Information Collection Request: Revision of currently approved collection; Title of Information
Collection: Medicare Authorization to Disclose Personal Health Information;

Use: Unless permitted or required by law, the Health Insurance Portability and Accountability Act (HIPAA) prohibits Medicare (a HIPAA covered entity) from disclosing an individual’s protected health information without a valid authorization. In order to be valid, an authorization must include specified
core elements and statements. Medicare
will make available to Medicare beneficiaries a standard, valid
authorization to enable beneficiaries to request the disclosure of their protected
health information. This standard authorization will simplify the process of requesting information disclosure for beneficiaries and minimize the response time for Medicare. The completed
authorization will allow Medicare to disclose an individual’s personal health information to a third party at the individual’s request. Form Number: CMS–10106 (OMB#: 0938–0930); Frequency: Reporting—On occasion; Affected Public: Individuals or households; Number of Respondents:

1,004,000; Total Annual Responses:

1,004,000; Total Annual Hours: 251,000. (For policy questions regarding this collection contact Lindsay Dixon-Brown
at 410–786–1178. For all other issues call 410–786–1326.)

6. Type of Information Collection Request: Extension without change of a currently approved collection; Title of Information Collection: 1932 State Plan Amendment Template; Use: Section 1932(a)(1)(A) of the Social Security Act (the Act) grants states the authority to
enroll Medicaid beneficiaries on a mandatory basis into managed care entities managed care organization (MCOs) and primary care case managers (PCCMs). Under this authority, a State can amend its Medicaid State plan to require certain categories of Medicaid beneficiaries to enroll in managed care entities without being out of compliance. This template may be used by States to easily modify their State plans if they choose to implement the provisions of section 1932(a)(1)(A).

The State Medicaid Agencies will complete the template. CMS will review
the information to determine if the State has met all the requirements of section 1932(a)(1)(A) and 42 CFR 438.50. If the requirements are met, CMS will approve
the amendment to the State’s title XIX plan giving the State the authority to
enroll Medicaid beneficiaries on a mandatory basis into managed care
entities MCOs and PCCMs. For a State to receive Medicaid funding, there must be an approved title XIX State plan;
Form Number: CMS–10120 (OMB#: 0938–0933); Frequency: Occasionally; Affected Public: State, Local, or Tribal Governments; Number of Respondents:

56; Total Annual Responses: 10; Total
Annual Hours: 100. (For policy questions regarding this collection
contact Camille Dobson at 410–786–
7065. For all other issues call 410–786– 1326.)

7. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: State Medicaid Health Information Technology (HIT) Plan (SMHP) and Model Checklist: Health Information Technology (HIT) Planning-Advance Planning Document (HIT P–APD); Use: Section 4201 of


### 9581 Federal Register/ Vol. 76, No. 34 / Friday, February 18, 2011 / Notices

Recovery Act establishes 100 percent Federal financial participation (FFP) as reimbursement to States for making incentive payments to providers for meaningful use of certified electronic health record technology and 90 percent FFP for administering these payments. Additionally, States are required to conduct oversight of this program and ensure no duplicate payments; thus, CMS is requiring States to submit information to CMS for prior approval before drawing down funding. These documents, if States choose to implement these flexibilities, will require a collection of information to effectuate these changes.

The State Medicaid agencies will complete the templates. CMS will
review the information to determine if the State has met all of the requirements of the Recovery Act provisions the States choose to implement. If the requirements are met, CMS will approve the amendments giving the State the authority to implement their Health Information Technology (HIT) strategy and implementation plans. For a State to receive Medicaid Title XIX funding, there must be an approved State Medicaid HIT Plan, Planning Advance Planning Document and Implementation Advance Planning Document; Form Number: CMS–10292 (OMB#: 0938–1088); Frequency: Yearly, Once, Occasionally; Affected Public: State, Local, or Tribal Governments; Number of Respondents: 56; Total Annual Responses: 56; Total Annual

Hours: 56. (For policy questions regarding this collection contact Sherry
Armstead at 410–786–4342. For all other issues call 410–786–1326.)

8. Type of Information Collection Request: Extension without change of a currently approved collection; Title of Information Collection: Provider Enrollment, Chain and Ownership System (PECOS) Security Consent Form;

Use: The primary function of the Medicare enrollment application is to obtain information about the provider or supplier and whether the provider or supplier meets Federal and/or State qualifications to participate in the Medicare program. In addition, the Medicare enrollment application gathers information regarding the provider or supplier’s practice location, the identity of the owners of the enrolling organization, and information necessary to establish the correct claims payment. In establishing a Web based application process, we allow providers and suppliers the ability to enroll in the Medicare program via the Internet. For these applicants, no security consent
form is needed to enroll or make a change in their Medicare enrollment information. These applicants receive complete access to their own enrollments through Internet-based Provider Enrollment, Chain and Ownership System (PECOS).

In order to allow a provider or supplier to delegate the Medicare credentialing process to another individual or organization, it is necessary to establish a Security Consent Form for those providers and suppliers who choose to have another individual or organization access their enrollment information and complete
enrollments on their behalf. These users could consist of administrative staff, independent contractors, or credentialing departments and are represented as Employer Organizations. Employer Organizations and its members must request access to enrollment data through a Security Consent Form. The security consent form replicates business service agreements between Medicare applicants and organizations providing
enrollment services.

We are proposing two different versions of the Security Consent Form. The form, once signed, mailed and approved, grants an employer organization or its member’s access to
all current and future enrollment data for the Medicare provider. Form Number: CMS–10220 (OMB#: 0938– 1035); Frequency: Occassionally; Affected Public: State, Local, or Tribal Governments; Number of Respondents:

197,500; Total Annual Responses:

197,500; Total Annual Hours: 49,375. (For policy questions regarding this
collection contact Alisha Banks at 410–
786–0671. 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.

To be assured consideration,
comments and recommendations for the proposed information collections must be received by the OMB desk officer at the address below, no later than 5 p.m. on March 21, 2011.

OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk Officer, Fax Number: (202) 395–6974,
E-mail: OIRA

_submission@omb.eop.gov.

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

[FR Doc. 2011–3748 Filed 2–17–11; 8:45 am]

**BILLING CODE 4120–01–P**

**DEPARTMENT OF HEALTH AND**
**HUMAN SERVICES**

**Administration for Children and**
**Families**

**Submission for OMB Review; Comment Request** 

Title: Strengthening Communities Fund (SCF) Performance Management and Evaluation Support.

OMB No.: New Collection. Description: This proposed information collection activity is to obtain information from participants in two Strengthening Communities Fund (SCF) programs: The Nonprofit Capacity Building Program and the State, Local, and Tribal Government Capacity Building Program. Both programs are designed to contribute to the economic recovery as authorized in the American Recovery and Reinvestment Act of 2009 (ARRA). The SCF evaluation is an important opportunity to examine outcomes achieved by the Strengthening Communities Fund and progress toward the objective of improving the capacity of organizations served by program grantees to address broad economic recovery issues in their communities.

The evaluation will be designed to assess progress and measure increased organizational capacity of each participating organization. The purpose of this request is to receive approval of
the data collection instruments that will be used in this study.

A significant amount of information is already being collected through program-specific OMB-approved PPR forms or is available through secondary sources. Proposed surveys and phone interviews are very brief to reduce the burden on respondents.

Respondents: