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                -                       the agency or agencies that issued and signed a document                    
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###### Department of Health and Human Services

###### Health Care Financing Administration 

          - [Document Identifier: HCFA-379] 

# 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                         *Paperwork@hcfa.gov,*                         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