### 30944 Federal Register/ Vol. 76, No. 103 / Friday, May 27, 2011 / Notices

**DEPARTMENT OF HEALTH AND HUMAN SERVICES** 

**Centers for Medicare & Medicaid Services** 

**[Document Identifier: CMS–222, CMS–287– 05, CMS–1771, and CMS–10008]** 

**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: Extension of currently approved collection; Title of Information Collection: Independent Rural Health Center/Freestanding Federally Qualified Health Center Cost Report and Supporting Regulations 42 CFR 413.20 and 42 CFR 413.24; Use: Providers of service in the Medicare program are required to submit annual information to achieve reimbursement for health care services rendered to Medicare beneficiaries. The Form CMS– 222 cost report is needed to determine the amount of reasonable cost due to the providers for furnishing medical services to Medicare beneficiaries; Form Number: CMS–222 (OMB# 0938–0107); Frequency: Yearly;Affected Public:Business or other for-profit and not-forprofit institutions; Number of Respondents: 5,812; Total Annual Responses: 5,812; Total Annual Hours: 290,600. (For policy questions regarding this collection contact Steve A. Raitzyk at 410–786–4599. For all other issues call 410–786–1326.)

2. Type of Information Collection Request: Extension without change of a currently approved collection; Title of Information Collection: Chain Home Office Cost Statement and supporting Regulations in 42 CFR 413.17 and 413.20; Use: The Form CMS–287–05 is filed annually by Chain Home Offices to report the information necessary for the determination of Medicare reimbursement to components of chain organizations. However, where providers are components of chain organizations, information included in the chain home office cost statement is in addition to that included in the provider cost report and is needed to determine whether payments are appropriate. Form Number: CMS–287– 05 (OMB# 0938–0202); Frequency: Yearly;Affected Public: Business or other for-profit and not-for-profit institutions; Number of Respondents: 1,541; Total Annual Responses: 1,541; Total Annual Hours: 718,106. (For policy questions regarding this collection contact Nadia Massuda at 410–786–5834. For all other issues call 410–786–1326.)

3. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR Section 424.103; Use: 42 CFR 424.103 (b) requires that before a nonparticipating hospital may be paid for emergency services rendered to a Medicare beneficiary, a statement must be submitted that is sufficiently comprehensive to support that an emergency existed. Form CMS–1771 contains a series of questions relating to the medical necessity of the emergency. The attending physician must attest that the hospitalization was required under the regulatory emergency definition (42 CFR 424.101) and give clinical documentation to support the claim. Form Number: CMS–1771 (OMB# 0938– 0023); Frequency: Yearly;Affected Public: Private sector—Business or other for-profit and not-for-profit institutions; Number of Respondents: 100; Total Annual Responses: 200; Total Annual Hours: 50. (For policy questions regarding this collection contact Shauntari Cheely at 410–786–1818. For all other issues call 410–786–1326.)

4. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Process and Information Required To Determine Eligibility of Drugs, Biologicals, and Radiopharmaceutical Agents for Transitional Pass-Through Status Under the Hospital Outpatient Prospective Payment System (OPPS); Use: Section 1833(t)(6) of the Social Security Act provides for temporary additional payments or ‘‘transitional pass-through payments’’ for certain drugs and biological agents. Interested parties such as hospitals, pharmaceutical companies, and physicians can apply for transitional pass-through payment for drugs and biologicals used with services covered under the OPPS. CMS uses this information to determine if the criteria for making a transitional pass-through payment are met and if an interim Healthcare Common Procedure Coding System (HCPCS) code for a new drug or biological is necessary. Form Number: CMS–10008 (OMB#: 0938–0802); Frequency: Once;Affected Public:Private sector—Business or other forprofit; Number of Respondents: 30; Total Annual Responses: 480; Total Annual Hours: 480. (For policy questions regarding this collection contact Christina Ritter Ph.D. at 410– 786–4636. For all other issues call 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 June 27, 2011. OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk Officer.

Fax Number: (202) 395–6974. E-mail: OIRA

_submission@omb.eop.gov.

Dated: May 20, 2011. Michelle Shortt, Director, Regulations Development Group, Office of Strategic Operations and Regulatory Affairs.

[FR Doc. 2011–13039 Filed 5–26–11; 8:45 am]

**BILLING CODE 4120–01–P**

**DEPARTMENT OF HEALTH AND HUMAN SERVICES** 

**Administration for Children and Families** 

**Proposed Information Collection Activity; Comment Request** 

Title: ACF–535 LIHEAP Quarterly Allocation Estimates.

OMB No. 0970–0037. Description: The LIHEAP Quarterly Allocation Estimates, ACF Form-535 is a one-page form that is sent to 50 State grantees and to the District of Columbia. It is also sent to Tribal Government grantees that receive over $1 million annually for the Low Income Home Energy Assistance Program (LIHEAP). Grantees are asked to complete and submit the form in the 4th quarter of each year. The data collected on the form are grantees estimates of obligations they expect to make each