29248 Federal Register / Vol. 76, No. 98 / Friday, May 20, 2011 / Notices 

the following issues. The CMS–855A 

enrollment form currently captures 

ownership/managerial information on 

providers. The data required under 

sections 6401 and 6001, however, is 

more specific than that currently 

obtained on the CMS–855A. CMS will 

therefore create four attachments to the 

CMS–855A—two for SNFs and the other 

two for physician-owned hospitals—to 

secure this information. In addition to 

the application changes triggered by 

ACA, CMS is making other revisions to 

the forms as well. 

This information collection request 

has been revised since the 60-day 

Federal Register notice published on 

March 22, 2011 (76 FR 13415). The 

group/clinic and individual burden has 

decreased due to the removal of a 

previously proposed supplier 

attachment. However, the overall 

burden hour estimate has increased 

slightly due to additional role-specific 

ownership and managerial control data 

collection for institutional providers. 

Form Number: CMS–855(A, B, I, R) 

(OMB#: 0938–0685); Frequency: Yearly; 

Affected Public: Private Sector; Business 

or other for-profit and not-for-profit 

institutions; Number of Respondents: 

440,450; Total Annual Responses: 

440,450; Total Annual Hours: 856,395. 

(For policy questions regarding this 

collection contact Kim McPhillips at 

410–786–5374. 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 20, 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 17, 2011. 

Martique Jones, 

Director, Regulations Development Group, 

Division-B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2011–12473 Filed 5–19–11; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–R–235] 

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: Revision of a currently 

approved collection; Title of 

Information Collection: Data Use 

Agreement (DUA) for Data Acquired 

from the Centers for Medicare & 

Medicaid Services (CMS); Use: The 

Privacy Act of 1976, § 552a requires the 

Centers for Medicare & Medicaid 

Services (CMS) to track all disclosures 

of the agency’s Personally Identifiable 

Information (PII) and the exceptions for 

these data releases. CMS is also required 

by the Health Insurance Portability and 

Accountability Act (HIPAA) of 1996 and 

the Federal Information Security 

Management Act (FISMA) of 2002 to 

properly protect all PII data maintained 

by the agency. When entities request 

CMS PII data, they enter into a Data Use 

Agreement (DUA) with CMS. The DUA 

stipulates that the recipient of CMS PII 

data must properly protect the data 

according to FISMA and also provide 

for its appropriate destruction at the 

completion of the project/study or the 

expiration date of the DUA. The DUA 

form enables the data recipient and 

CMS to document the request and 

approval for release of CMS PII data. 

The form requires the submitter to 

provide the Requestor’s organization; 

project/study name; CMS contract 

number (if applicable); data descriptions 

and the years of the data; retention date; 

attachments to the agreement; name, 

title, contact information to include 

address, city, state, zip code, phone, email, signature and date signed by the 

requester and custodian; disclosure 

provision; name of Federal Agency 

sponsor; Federal Representative name, 

title, contact information, signature, 

date; CMS representative name, title, 

contact information, signature and date; 

and concurrence/non-concurrence 

signatures and dates from 3 CMS 

System Manager or Business Owners. 

While the data elements collected are 

not subject to change, the 

individualized clauses that are 

incorporated into any specific DUA are 

subject to change based on a specific 

case or situation such as disclosures to 

states, oversight agencies or DUAs for 

disproportionate share hospital (DSH) 

data requests as well as updates to 

DUAs with additional data descriptions, 

changes to the requestor or adding 

custodians to current DUAs. Form 

Number: CMS–R–235 (OCN: 0938–0734) 

Frequency: Once; Affected Public: 

Private Sector—Business or other Forprofits and Not-for-profit Institutions; 

Number of Respondents: 2,200; Number 

of Responses: 2,200; Total Annual 

Hours: 916. (For policy questions 

regarding this collection, contact Sharon 

Kavanagh at 410–786–5441. 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.gov/Paperwork

ReductionActof1995/PRAL/

list.asp#TopOfPage 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 July 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. 

Dated: May 17, 2011. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2011–12472 Filed 5–19–11; 8:45 am] 

BILLING CODE 4120–01–P 


jlentini on DSK4TPTVN1PROD with NOTICES