Federal Register / Vol. 74, No. 242 / Friday, December 18, 2009 / Notices 67227 

inspection at the Federal Reserve Bank 

indicated. The applications also will be 

available for inspection at the offices of 

the Board of Governors. Interested 

persons may express their views in 

writing on the standards enumerated in 

the BHC Act (12 U.S.C. 1842(c)). If the 

proposal also involves the acquisition of 

a nonbanking company, the review also 

includes whether the acquisition of the 

nonbanking company complies with the 

standards in section 4 of the BHC Act 

(12 U.S.C. 1843). Unless otherwise 

noted, nonbanking activities will be 

conducted throughout the United States. 

Additional information on all bank 

holding companies may be obtained 

from the National Information Center 

website at www.ffiec.gov/nic/. 

Unless otherwise noted, comments 

regarding each of these applications 

must be received at the Reserve Bank 

indicated or the offices of the Board of 

Governors not later than January 14, 

2010. 

A. Federal Reserve Bank of Kansas 

City (Dennis Denney, Assistant Vice 

President) 1 Memorial Drive, Kansas 

City, Missouri 64198–0001: 

1. GFP Financial Services Company, 

Tulsa, Oklahoma; to become a bank 

holding company by acquiring 65.04 

percent of the voting shares of First 

Pryor Bancorp, Inc., and First Pryority 

Bank, both in Pryor, Oklahoma. 

Board of Governors of the Federal Reserve 

System, December 15, 2009. 

Robert deV. Frierson, 

Deputy Secretary of the Board. 

[FR Doc. E9–30100 Filed 12–17–09; 8:45 am] 

BILLING CODE 6210–01–S 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–3070, CMS–576/ 

576A, CMS–416, CMS–10028 and CMS– 

2744, CMS–10088, CMS–R–142, CMS–10197 

and CMS–10304] 

Agency Information Collection 

Activities: Proposed Collection; 

Comment Request 

AGENCY: Centers for Medicare & 

Medicaid Services. 

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: Intermediate 

Care Facility (ICF) for the Mentally 

Retarded (MR) or Persons with Related 

Conditions Survey Report Form and 

Supporting Regulations at 42 CFR 

442.30, 483.410, 483.420, 483.440, 

483.450 and 483.460; Use: This survey 

form is needed to ensure ICF/MR 

provider and client characteristics are 

available and updated annually for the 

federal government’s Online Survey 

Certification and Reporting (OSCAR) 

system. It is required for the provider to 

fill out at the time of the annual 

recertification or initial certification 

survey conducted by the State Medicaid 

agency. The team leader for the state 

survey team must review and approve 

the completed form before completion 

of the survey. The State Medicaid 

survey agency is responsible for 

transferring the 3070 information into 

OSCAR. Form Number: CMS–3070 

(OMB#: 0938–0062); Frequency: 

Reporting—Yearly; Affected Public: 

Private Sector: Business or other forprofits and Not-for-profit institutions; 

Number of Respondents: 6,437; Total 

Annual Responses: 6,437; Total Annual 

Hours: 19,311. (For policy questions 

regarding this collection contact Kelley 

Tinsley at 410–786–6664. For all other 

issues call 410–786–1326.) 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Organ 

Procurement Organization’s (OPO’s) 

Health Insurance Benefits Agreement 

and Supporting Regulations at 42 CFR 

486.301–486.348; Use: The information 

provided on this form serves as a basis 

for continuing the agreements with CMS 

and the 580 OPOs for participation in 

the Medicare and Medicaid programs 

for reimbursement of service. Form 

Number: CMS–576/576A (OMB#: 0938– 

0512); Frequency: Reporting— 

Occasionally; Affected Public: Private 

Sector: Business or other for-profits and 

Not-for-profit institutions; Number of 

Respondents: 58; Total Annual 

Responses: 58; Total Annual Hours: 

116. (For policy questions regarding this 

collection contact Michele Walton at 

410–786–3353. For all other issues call 

410–786–1326.) 

3. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Annual Early 

and Periodic Screening, Diagnostic and 

Treatment (EPSDT) Services 

Participation Report; Form Number: 

CMS–416 (OMB#: 0938–0354); Use: 

States are required to submit an annual 

report on the provision of EPSDT 

services pursuant to section 

1902(a)(43)(D) of the Social Security 

Act. These reports provide CMS with 

data necessary to assess the 

effectiveness of State EPSDT programs, 

to determine a State’s results in 

achieving its participation goal and to 

respond to inquiries. Respondents are 

State Medicaid Agencies. The data is 

due April 1 of every year so States need 

to have the form and instructions as 

soon as possible in order to report 

timely. Frequency: Yearly; Affected 

Public: State, Tribal and Local 

governments; Number of Respondents: 

56; Total Annual Responses: 56; Total 

Annual Hours: 504. (For policy 

questions regarding this collection 

contact Cindy Ruff at 410–786–5916. 

For all other issues call 410–786–1326.) 

4. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title of 

Information Collection: State Health 

Insurance Assistance Program (SHIP) 

Client Contact Form, Public and Media 

Form, and Resource Report Form; Form 

Number: CMS–10028 (OMB#: 0938– 

0850); Use: The current Client Contact 

form, Public and Media Activity Report 

form, and Resource Report have been 

used to collect data to evaluate program 

effectiveness and improvement. In 

addition, the 2007–2009 State Health 

Insurance Program (SHIP) Performance 

Assessment Workgroup (comprised of 

SHIP Directors and representatives from 

external organizations such as the 

Administration on Aging), in a report to 

CMS, recommended that changes be 

made to the forms in order to enhance 

the ability to measure performance and 

program evaluation for each SHIP; add 

additional data collection elements as 

requested by Congress and SHIPs 

(Limited English Proficiency and Dual 

Mentally Disabled); and reduce the 

burden of data submission by counselor 

as a result of the ability to pre-populate 

certain data cells. The information 

collected is used to fulfill the reporting 

requirements described in Section 

4360(f) of OBRA 1990. Also, the data 

will be accumulated and analyzed to 


sroberts on DSKD5P82C1PROD with NOTICES
67228 Federal Register / Vol. 74, No. 242 / Friday, December 18, 2009 / Notices 

measure SHIP performance in order to 

determine whether and to what extent 

the SHIPs have met the goals of 

improved CMS customer service to 

beneficiaries and better understanding 

by beneficiaries of their health 

insurance options. Further, the 

information will be used in the 

administration of the grants, to measure 

performance and appropriate use of the 

funds by the state grantees, to identify 

gaps in services and technical support 

needed by SHIPs, and to identify and 

share best practices. Frequency: Yearly; 

Affected Public: State, Tribal and Local 

governments; Number of Respondents: 

20,778; Total Annual Responses: 

1,672,454; Total Annual Hours: 139,475. 

(For policy questions regarding this 

collection contact Barbara Childers at 

410–786–7610. For all other issues call 

410–786–1326.) 

5. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: End Stage Renal 

Disease (ESRD) Medical Information 

Facility Survey; Form Number: CMS– 

2744 (OMB#: 0938–0447); Use: The End 

Stage Renal Disease (ESRD) Medical 

Information Facility Survey form (CMS– 

2744) is completed annually by 

Medicare-approved providers of dialysis 

and transplant services. The CMS–2744 

is designed to collect information 

concerning treatment trends, utilization 

of services and patterns of practice in 

treating ESRD patients. The information 

is used to assess and evaluate the local, 

regional and national levels of medical 

and social impact of ESRD care and is 

used extensively by researchers and 

suppliers of services for trend analysis. 

The information is available on the CMS 

Dialysis Facility Compare Web site and 

will enable patients to make informed 

decisions about their care by comparing 

dialysis facilities in their area. 

Frequency: Yearly; Affected Public: 

Business or other for-profit, Not-forprofit institutions; Number of 

Respondents: 5,465; Total Annual 

Responses: 5,465; Total Annual Hours: 

43,720. (For policy questions regarding 

this collection contact Connie Cole at 

410–786–0257. For all other issues call 

410–786–1326.) 

6. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title of 

Information Collection: Notification of 

Fiscal Intermediaries and CMS of colocated Medicare providers and 

Supporting Regulations in 42 CFR 

412.22 and 412.533; Use: Many longterm care hospitals (LTCHs) are colocated with other Medicare providers 

(acute care hospitals, IRFs, SNFs, 

psychiatric facilities), which leads to 

potential gaming of the Medicare system 

based on patient shifting. CMS is 

requiring LTCHs to notify fiscal 

intermediaries K (FIs), Medicare 

Administrative Contractors (MACs) and 

CMS of co-located providers and 

establish policies to limit payment 

abuse that will be based on FIs tracking 

patient movement among these colocated providers. Form Number: CMS– 

10088 (OMB#: 0938–0897); Frequency: 

Occasionally; Affected Public: Private 

Sector, Business or other for-profits and 

Not-for-profit institutions; Number of 

Respondents: 25; Total Annual 

Responses: 25; Total Annual Hours: 

6.25. (For policy questions regarding 

this collection contact Judith Richter at 

410–786–2590. For all other issues call 

410–786–1326.) 

7. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Examination 

and Treatment for Emergency Medical 

Conditions and Women in Labor 

(EMTALA), 42 CFR 482.12, 488.18, 

489.20, and 489.24; Use: This collection 

contains the requirements for hospitals 

in effort to prevent them from 

inappropriately transferring individuals 

with emergency medical conditions, as 

mandated by Congress. CMS uses this 

information to help assure compliance 

with this mandate. This information is 

not contained elsewhere in regulations. 

Form Number: CMS–R–142 (OMB#: 

0938–0667); Frequency: Daily; Affected 

Public: Individuals or households; 

Private Sector; Number of Respondents: 

6,149; Total Annual Responses: 6,149; 

Total Annual Hours: 1. (For policy 

questions regarding this collection 

contact Renate Rockwell at 410–786– 

4645. For all other issues call 410–786– 

1326.) 

8. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title of 

Information Collection: Evaluation of 

the Medicare National Competitive 

Bidding Program for DME; Use: Data 

collection materials consisting of 

beneficiary surveys and interview/ 

discussion group guides are necessary to 

conduct the congressionally mandated 

evaluation of the Medicare National 

Competitive Bidding Program. Medicare 

Modernization (MMA) Section 303(d) 

requires a Report to Congress on the 

program, covering program savings, 

reductions in cost sharing, impacts on 

access to and quality of affected goods 

and services, and beneficiary 

satisfaction. This project’s purpose is to 

provide information for this Report to 

Congress. Due to substantial legislative 

and regulatory delays in program 

implementation, the Report to Congress 

in 2011 will be released just as the 

program is being implemented, and 

before the evaluation is complete. This 

project will continue after the Report to 

Congress, to evaluate the impact of the 

program on beneficiaries, on Medicare 

costs, and on changes in the Medicare 

Durable Medical Equipment, 

Prosthetics, Orthotics and Supplies 

(DMEPOS) market. Form Number: 

CMS–10197 (OMB#: 0938–1015); 

Frequency: Occasionally; Affected 

Public: Individuals or households, 

Private Sector, Business or other forprofits, not-for-profit institutions, and 

Federal Government; Number of 

Respondents: 8,466; Total Annual 

Responses: 8,466; Total Annual Hours: 

4,338. (For policy questions regarding 

this collection contact Ann Meadow at 

410–786–6602. For all other issues call 

410–786–1326.) 

9. Type of Information Collection 

Request: New collection; Title of 

Information Collection: Information 

Collection Requirements and 

Supporting Information for Chronic 

Kidney Disease Surveys under the 9th 

Scope of Work; Form Number: CMS– 

10304 (OMB#: 0938–New); Use: The 

Centers for Medicare & Medicaid 

Services (CMS) and the U.S. Department 

of Health and Human Services (DHHS) 

are requesting OMB clearance for the 

Chronic Kidney Disease (CKD) Partner 

Survey and the Chronic Kidney Disease 

(CKD) Provider Survey. The Prevention 

CKD Theme is a component of the 

Prevention Theme of the Quality 

Improvement Organization (QIO) 

Program’s 9th Scope of Work (SOW). 

The statutory authority for this scope of 

work is found in Part B of Title XI of 

the Social Security Act (the Act) as 

amended by the Peer Review 

Improvement Act of 1982. The Act 

established the Utilization and Quality 

Control Peer Review Organization 

Program, now known as the Quality 

Improvement Organization (QIO) 

Program. 

The goal of the Prevention CKD 

Theme is to detect the incidence, 

decrease the progression of CKD, and 

improve care among Medicare 

beneficiaries through provider adoption 

of timely and effective quality of care 

interventions; participation in quality 

incentive initiatives; beneficiary 

education; and key linkages and 

collaborations for system change at the 

state and local level. In addition to 

improving the quality of care for the 

elderly and frail-elderly, this Theme 

aims to reduce the rate of Medicare 

entitlement by disability through the 

delay and prevention of end-stage renal 

disease (ESRD); thus resulting in higher 


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Federal Register / Vol. 74, No. 242 / Friday, December 18, 2009 / Notices 67229 

quality care and significant savings to 

the Medicare Trust Fund. 

The CKD Partner Survey constitutes a 

new information collection to be used 

by CMS to obtain information on how 

QIO collaboration with partners 

facilitates systems change within the 

QIO’s respective state. The CKD Partner 

Survey will be a census administered to 

350 collaborative partners in the 9th 

SOW. The CKD Partner Survey will be 

administered via telephone. Responses 

will be entered into a pre-programmed 

Computer-Assisted Telephone 

Interviewing (CATI) interface. The 

results of the survey shall be used for 

inpatient quality indicators (IQI) by the 

QIO. CMS will also use the results to 

assess how partner organizations and 

their perspective of the QIO’s role are 

implementing system change. 

Similarly, the CKD Provider Survey 

constitutes a new information collection 

to be used by CMS to obtain information 

on how QIO collaboration with 

physician practices facilitates systems 

change within the QIO’s respective 

state. The CKD Provider Survey will be 

administered via telephone and the 

Web. Responses collected by phone will 

be entered into a pre-programmed 

Computer-Assisted Telephone 

Interviewing (CATI) interface. 

Responses collected by Web will be 

housed on a secure server and database. 

The results of the survey shall be used 

for inpatient quality indicators (IQI) by 

the QIO. CMS will also use the results 

to assess how physicians’ practices and 

their perspective of the QIO’s role are 

implementing system change. 

Frequency: Yearly; Affected Public: 

Private Sector—Business or other forprofits and Not-for profit institutions; 

Number of Respondents: 1,350; Total 

Annual Responses: 1,350; Total Annual 

Hours: 337.5. (For policy questions 

regarding this collection contact Robert 

Kambic at 410–786–1515. 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 on (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 February 16, 2010: 

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: December 11, 2009. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. E9–30176 Filed 12–17–09; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10299, CMS– 

10300 and CMS–10294] 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request 

AGENCY: Centers for Medicare & 

Medicaid Services. 

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: New Collection; Title of 

Information Collection: State Plan 

Amendment Template for the Option to 

Cover Certain Children and Pregnant 

Women Lawfully residing in U.S.; Use: 

This new option for State Medicaid and 

Children Health Insurance Programs 

(CHIP) was provided by section 214 of 

the Children’s Health Insurance 

Program Reauthorization Act of 2009, 

Public Law 111–3, which amends 

section 1902 of the Social Security Act. 

To select this option, a State Medicaid 

or CHIP agency will complete a 

template page and submit it for approval 

as part of their State Plan. Form 

Number: CMS–10299 (OMB#: 0938– 

NEW); Frequency: Reporting—Once and 

occasionally; Affected Public: State, 

Local, or Tribal Governments; Number 

of Respondents: 51; Total Annual 

Responses: 51; Total Annual Hours: 51. 

(For policy questions regarding this 

collection contact Bob Tomlinson at 

410–786–5907. For all other issues call 

410–786–1326.) 

2. Type of Information Collection 

Request: New collection; Title of 

Information Collection: State Plan 

Amendment Templates for Additional 

State Plan Option for Providing 

Premium Assistance under Title XIX 

and XXI; Use: Section 301 of the 

Children’s Health Insurance Program 

Reauthorization Act of 2009 (CHIPRA), 

Public Law 111–3, adds Section 

2105(c)(10) of the Social Security Act 

effective April 1, 2009, to offer States a 

new option to provide premium 

assistance subsidies to enroll targeted 

low-income individuals under age 19, 

and their parents in qualified employersponsored coverage. To elect this 

option, a State Children’s Health 

Insurance Program agency will complete 

the template pages and submit it for 

approval as part of a State plan 

amendment. Form Number: CMS–10300 

(OMB#: 0938–New); Frequency: 

Reporting—Once and On occasion; 

Affected Public: State, Local or Tribal 

Government; Number of Respondents: 

51; Total Annual Responses: 51; Total 

Annual Hours: 255. (For policy 

questions regarding this collection 

contact Stacey Green at 410–786–6102. 

For all other issues call 410–786–1326.) 

3. Type of Information Collection 

Request: New collection; Title of 

Information Collection: Program 

Evaluation of the Eighth and Ninth 

Scope of Work Quality Improvement 

Organization Program; Use: The 

statutory authority for the Quality 

Improvement Organization (QIO) 

Program is found in Part B of Title XI 

of the Social Security Act, as amended 

by the Peer Review Improvement Act of 

1982. The Social Security Act 

established the Utilization and Quality 

Control Peer Review Organization 

Program, now known as the QIO 

Program. The statutory mission of the 


sroberts on DSKD5P82C1PROD with NOTICES