[Federal Register Volume 66, Number 91 (Thursday, May 10, 2001)]
[Notices]
[Page 23944]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 01-11735]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

[Document Identifier: HCFA-379]


Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Health Care Financing Administration, HHS.
    In compliance with the requirement of section 3506(c)(2)(A) of the 
Paperwork Reduction Act of 1995, the Health Care Financing 
Administration (HCFA), 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 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.
    Type of Information Collection Request: Extension of a currently 
approved collection;
    Title of Information Collection: The Financial Statement of Debtor 
and Supporting Regulations in 42 CFR, Section 405.376;
    Form No.: HCFA-379 (OMB# 0938-0270);
    Use: This form is used to collect financial information which is 
needed to evaluate requests from physicians/suppliers to pay 
indebtedness under an extended repayment schedule, or to compromise a 
debt less than the full amount.;
    Frequency: Other: As needed;
    Affected Public: Business or other for-profit, and Individuals or 
Households;
    Number of Respondents: 500;
    Total Annual Responses: 500;
    Total Annual Hours: 1,000.
    To obtain copies of the supporting statement and any related forms 
for the proposed paperwork collections referenced above, access HCFA's 
Web Site address at http://www.hcfa.gov/regs/prdact95.htm, or E-mail 
your request, including your address, phone number, OMB number, and 
HCFA document identifier, to <a href="/cdn-cgi/l/email-protection#580839283d2a2f372a3318303b3e39763f372e"><span class="__cf_email__" data-cfemail="2b7b4a5b4e595c4459406b43484d4a054c445d">[email protected]</span></a>, or call the Reports 
Clearance Office on (410) 786-1326. Written comments and 
recommendations for the proposed information collections must be mailed 
within 60 days of this notice directly to the HCFA Paperwork Clearance 
Officer designated at the following address: HCFA, Office of 
Information Services, Security and Standards Group, Division of HCFA 
Enterprise Standards, Attention: Dawn Willinghan, HCFA-379, Room N2-14-
26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

    Dated: May 2, 2001.
John P. Burke III,
HCFA Reports Clearance Officer, HCFA Office of Information Services, 
Security and Standards Group, Division of HCFA Enterprise Standards.
[FR Doc. 01-11735 Filed 5-9-01; 8:45 am]
BILLING CODE 4120-03-P


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