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

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


### 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 trackingpatient 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


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

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