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[Federal Register Volume 77, Number 116 (Friday, June 15, 2012)]
[Notices]
[Pages 35982-35983]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-14673]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-10221, CMS-855I and CMS-855R]

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: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection: Worksheet for Recording Results of Medicare Site Visits of 
Independent Diagnostic Testing Facilities (IDTFs); Use: The worksheet 
(form) was developed, approved through the Office of Management and 
Budget and implemented to allow for CMS to have a standard format to 
collect and verify information regarding the compliance of independent 
diagnostic testing facilities (IDTFs) with the performance standards 
found in 42 CFR 410.33(g). This previously approved form was allowed to 
expire in error. CMS is now seeking re-instatement of the use of this 
form.
    The worksheet is used to collect and record information obtained on 
IDTF site visits; the data collected during site

[[Page 35983]]

visits facilitates the verification of the accuracy and completeness of 
the information the IDTF furnished on its CMS-855B enrollment 
application. The worksheet is completed by CMS or its contractors. Some 
of the answers to the questions/data elements on the worksheet are 
verbally furnished by the IDTF during the site visit; Form Number: CMS-
10221 (OCN 0938-1029); Frequency: Occasionally; Affected Public: 
Private Sector (Business or other for-profits); Number of Respondents: 
2,000; Total Annual Responses: 2,000; Total Annual Hours: 4,000. (For 
policy questions regarding this collection contact Michael Collett at 
410-786-6121. For all other issues call 410-786-1326.)
    2. Type of Information Collection Request: Revision of a currently 
approved collection. Title of Information Collection: Medicare 
Enrollment Application for Physician and Non-Physician Practitioners. 
Use: Health care practitioners who wish to enroll in the Medicare 
program must complete the CMS 855I enrollment application. It is 
submitted at the time the applicant first requests a Medicare billing 
number. The application is used by the Medicare Administrative 
Contractor (MAC), to collect data to assure the applicant has the 
necessary professional and/or business credentials to provide the 
health care services for which they intend to bill Medicare including 
information that allows the MAC to correctly price, process and pay the 
applicant's claims. It also gathers information that allows the MAC to 
ensure that the practitioner is not sanctioned from the Medicare 
program, or debarred, suspended or excluded from any other Federal 
agency or program. Form Number: CMS-855I (OCN: 0938-0685). Frequency: 
Once and Occasionally. Affected Public: Private Sector (Business or 
other for-profit and not-for-profit institutions). Number of 
Respondents: 345,000. Total Annual Responses: 345,000. Total Annual 
Hours: 824,000. (For policy questions regarding this collection contact 
Kimberly McPhillips at 410-786-5374. For all other issues call 410-786-
1326.)
    3. Type of Information Collection Request: New collection. Title of 
Information Collection: Medicare Enrollment Application--Reassignment 
of Medicare Benefits. Use: Health care practitioners who wish to 
reassign their benefits in the Medicare program must complete the CMS 
855R enrollment application. It is submitted at the time the physician 
or non-physician practitioner first requests reassignment of his/her 
Medicare benefits to a group practice, as well as any subsequent 
reassignments or terminations of established reassignments as requested 
by the physician or non-physician practitioner. The application is used 
by the Medicare Administrative Contractor (MAC) to collect data to 
assure the applicant has the necessary information that allows the MAC 
to correctly establish or terminate the reassignment. Form Number: CMS-
855R (OCN: 0938-New). Frequency: Occasionally. Affected Public: Private 
Sector (Business or other for-profit and not-for-profit institutions). 
Number of Respondents: 100,000. Total Annual Responses: 100,000. Total 
Annual Hours: 50,000. (For policy questions regarding this collection 
contact Kimberly McPhillips at 410-786-5374. 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 
Email 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 July 16, 2012.

OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk 
Officer, Fax Number: (202) 395-6974, Email: OIRA_submission@omb.eop.gov.

    Dated: June 12, 2012.
Martique Jones,
Director, Regulations Development Group, Division B, Office of 
Strategic Operations and Regulatory Affairs.
[FR Doc. 2012-14673 Filed 6-14-12; 8:45 am]
BILLING CODE 4120-01-P
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