6278 Federal Register / Vol. 81, No. 24 / Friday, February 5, 2016 / Notices 

Emergency and Foreign Hospital 

Services; Use: Section 1866 of the Social 

Security Act states that any provider of 

services shall be qualified to participate 

in the Medicare program and shall be 

eligible for payments under Medicare if 

it files an agreement with the Secretary 

to meet the conditions outlined in this 

section of the Act. Section 1814 (d)(1) of 

the Social Security Act and 42 CFR 

424.100, allows payment of Medicare 

benefits for a Medicare beneficiary to a 

nonparticipating hospital that does not 

have an agreement in effect with the 

Centers for Medicare and Medicaid 

Services. These payments can be made 

if such services were emergency 

services and if CMS would be required 

to make the payment if the hospital had 

an agreement in effect and met the 

conditions of payment. This form is 

used in connection with claims for 

emergency hospital services provided 

by hospitals that do not have an 

agreement in effect under Section 1866 

of the Social Security Act. As specified 

in 42 CFR 424.103(b), before a nonparticipating hospital may be paid for 

emergency services rendered to a 

Medicare beneficiary, a statement must 

be submitted that is sufficiently 

comprehensive to support that an 

emergency existed. Form CMS–1771 

contains a series of questions relating to 

the medical necessity of the emergency. 

The attending physician must attest that 

the hospitalization was required under 

the regulatory emergency definition and 

give clinical documentation to support 

the claim. A photocopy of the 

beneficiary’s hospital records may be 

used in lieu of the CMS–1771 if the 

records contain all the information 

required by the form. Form Number: 

CMS–1771 (OMB control number: 

0938–0023); Frequency: Annually; 

Affected Public: Private sector (Business 

or other for-profits and Not-for-profit 

institutions); Number of Respondents: 

100; Total Annual Responses: 200; Total 

Annual Hours: 50. (For policy questions 

regarding this collection contact 

Shauntari Cheely at 410–786–1818.) 

4. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Medicare 

Uniform Institutional Provider Bill and 

Supporting Regulations in 42 CFR 

424.5; Use: Section 42 CFR 424.5(a)(5) 

requires providers of services to submit 

a claim for payment prior to any 

Medicare reimbursement. Charges billed 

are coded by revenue codes. The bill 

specifies diagnoses according to the 

International Classification of Diseases, 

Ninth Edition (ICD–9–CM) code. 

Inpatient procedures are identified by 

ICD–9–CM codes, and outpatient 

procedures are described using the CMS 

Common Procedure Coding System 

(HCPCS). These are standard systems of 

identification for all major health 

insurance claims payers. Submission of 

information on the CMS–1450 permits 

Medicare intermediaries to receive 

consistent data for proper payment. 

Form Numbers: CMS–1450 (UB–04) 

(OMB control number: 0938–0997); 

Frequency: On occasion; Affected 

Public: Private sector (Business or other 

for-profit and Not-for-profit 

institutions); Number of Respondents: 

53,111; Total Annual Responses: 

181,909,654; Total Annual Hours: 

1,567,455. (For policy questions 

regarding this collection contact Matt 

Klischer at 410–786–7488.) 

5. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Health 

Insurance Common Claims Form and 

Supporting Regulations at 42 CFR part 

424, subpart C; Use: The Form CMS– 

1500 answers the needs of many health 

insurers. It is the basic form prescribed 

by CMS for the Medicare program for 

claims from physicians and suppliers. 

The Medicaid State Agencies, 

CHAMPUS/TriCare, Blue Cross/Blue 

Shield Plans, the Federal Employees 

Health Benefit Plan, and several private 

health plans also use it; it is the de facto 

standard ‘‘professional’’ claim form. 

Medicare carriers use the data collected 

on the CMS–1500 and the CMS–1490S 

to determine the proper amount of 

reimbursement for Part B medical and 

other health services (as listed in section 

1861(s) of the Social Security Act) 

provided by physicians and suppliers to 

beneficiaries. The CMS–1500 is 

submitted by physicians/suppliers for 

all Part B Medicare. Serving as a 

common claim form, the CMS–1500 can 

be used by other third-party payers 

(commercial and nonprofit health 

insurers) and other Federal programs 

(e.g., CHAMPUS/TriCare, Railroad 

Retirement Board (RRB), and Medicaid). 

However, as the CMS–1500 displays 

data items required for other third-party 

payers in addition to Medicare, the form 

is considered too complex for use by 

beneficiaries when they file their own 

claims. Therefore, the CMS–1490S 

(Patient’s Request for Medicare 

Payment) was explicitly developed for 

easy use by beneficiaries who file their 

own claims. The form can be obtained 

from any Social Security office or 

Medicare carrier. Form Number: CMS– 

1500(02–12), CMS–1490S (OMB control 

number: 0938–1197) Frequency: On 

occasion; Affected Public: State, Local, 

or Tribal Governments, Private sector 

(Business or other-for-profit and Not-forprofit institutions); Number of 

Respondents: 1,448,346; Total Annual 

Responses: 988,005,045; Total Annual 

Hours: 21,418,336. (For policy questions 

regarding this collection contact 

Shannon Seales at 410–786–4089.) 

Dated: February 2, 2016. 

William N. Parham, III, 

Director, Paperwork Reduction Staff, Office 

of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 2016–02278 Filed 2–4–16; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Health Resources and Services 

Administration 

National Vaccine Injury Compensation 

Program; List of Petitions Received 

AGENCY: Health Resources and Services 

Administration, HHS. 

ACTION: Notice. 

SUMMARY: The Health Resources and 

Services Administration (HRSA) is 

publishing this notice of petitions 

received under the National Vaccine 

Injury Compensation Program (the 

Program), as required by Section 

2112(b)(2) of the Public Health Service 

(PHS) Act, as amended. While the 

Secretary of Health and Human Services 

is named as the respondent in all 

proceedings brought by the filing of 

petitions for compensation under the 

Program, the United States Court of 

Federal Claims is charged by statute 

with responsibility for considering and 

acting upon the petitions. 

FOR FURTHER INFORMATION CONTACT: For 

information about requirements for 

filing petitions, and the Program in 

general, contact the Clerk, United States 

Court of Federal Claims, 717 Madison 

Place NW., Washington, DC 20005, 

(202) 357–6400. For information on 

HRSA’s role in the Program, contact the 

Director, National Vaccine Injury 

Compensation Program, 5600 Fishers 

Lane, Room 11C–26, Rockville, MD 

20857; (301) 443–6593, or visit our Web 

site at: http://www.hrsa.gov/

vaccinecompensation/index.html. 

SUPPLEMENTARY INFORMATION: The 

Program provides a system of no-fault 

compensation for certain individuals 

who have been injured by specified 

childhood vaccines. Subtitle 2 of Title 

XXI of the PHS Act, 42 U.S.C. 300aa– 

10 et seq., provides that those seeking 

compensation are to file a petition with 

the U.S. Court of Federal Claims and to 

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Federal Register / Vol. 81, No. 24 / Friday, February 5, 2016 / Notices 6279 

serve a copy of the petition on the 

Secretary of Health and Human 

Services, who is named as the 

respondent in each proceeding. The 

Secretary has delegated this 

responsibility under the Program to 

HRSA. The Court is directed by statute 

to appoint special masters who take 

evidence, conduct hearings as 

appropriate, and make initial decisions 

as to eligibility for, and amount of, 

compensation. 

A petition may be filed with respect 

to injuries, disabilities, illnesses, 

conditions, and deaths resulting from 

vaccines described in the Vaccine Injury 

Table (the Table) set forth at 42 CFR 

100.3. This Table lists for each covered 

childhood vaccine the conditions that 

may lead to compensation and, for each 

condition, the time period for 

occurrence of the first symptom or 

manifestation of onset or of significant 

aggravation after vaccine 

administration. Compensation may also 

be awarded for conditions not listed in 

the Table and for conditions that are 

manifested outside the time periods 

specified in the Table, but only if the 

petitioner shows that the condition was 

caused by one of the listed vaccines. 

Section 2112(b)(2) of the PHS Act, 42 

U.S.C. 300aa–12(b)(2), requires that 

‘‘[w]ithin 30 days after the Secretary 

receives service of any petition filed 

under section 2111 the Secretary shall 

publish notice of such petition in the 

Federal Register.’’ Set forth below is a 

list of petitions received by HRSA on 

December 1, 2015, through December 

31, 2015. This list provides the name of 

petitioner, city and state of vaccination 

(if unknown then city and state of 

person or attorney filing claim), and 

case number. In cases where the Court 

has redacted the name of a petitioner 

and/or the case number, the list reflects 

such redaction. 

Section 2112(b)(2) also provides that 

the special master ‘‘shall afford all 

interested persons an opportunity to 

submit relevant, written information’’ 

relating to the following: 

1. The existence of evidence ‘‘that 

there is not a preponderance of the 

evidence that the illness, disability, 

injury, condition, or death described in 

the petition is due to factors unrelated 

to the administration of the vaccine 

described in the petition,’’ and 

2. Any allegation in a petition that the 

petitioner either: 

a. ‘‘[S]ustained, or had significantly 

aggravated, any illness, disability, 

injury, or condition not set forth in the 

Vaccine Injury Table but which was 

caused by’’ one of the vaccines referred 

to in the Table, or 

b. ‘‘[S]ustained, or had significantly 

aggravated, any illness, disability, 

injury, or condition set forth in the 

Vaccine Injury Table the first symptom 

or manifestation of the onset or 

significant aggravation of which did not 

occur within the time period set forth in 

the Table but which was caused by a 

vaccine’’ referred to in the Table. 

In accordance with Section 

2112(b)(2), all interested persons may 

submit written information relevant to 

the issues described above in the case of 

the petitions listed below. Any person 

choosing to do so should file an original 

and three (3) copies of the information 

with the Clerk of the U.S. Court of 

Federal Claims at the address listed 

above (under the heading ‘‘For Further 

Information Contact’’), with a copy to 

HRSA addressed to Director, Division of 

Injury Compensation Programs, 

Healthcare Systems Bureau, 5600 

Fishers Lane, Room 11C–26, Rockville, 

MD 20857. The Court’s caption 

(Petitioner’s Name v. Secretary of Health 

and Human Services) and the docket 

number assigned to the petition should 

be used as the caption for the written 

submission. Chapter 35 of title 44, 

United States Code, related to 

paperwork reduction, does not apply to 

information required for purposes of 

carrying out the Program. 

Dated: January 21, 2016. 

James Macrae, 

Acting Administrator. 

List of Petitions Filed 

1. Sandra Malone, Germantown, 

Tennessee, Court of Federal Claims 

No: 15–1439V. 

2. Robert Petrillo, Revere, 

Massachusetts, Court of Federal 

Claims No: 15–1441V. 

3. Nikysha Cyrus on behalf of Jayden A. 

Baker, Pittsburgh, Pennsylvania, 

Court of Federal Claims No: 15– 

1442V. 

4. Robert Niziol on behalf of S. N., 

Tenafly, New Jersey, Court of Federal 

Claims No: 15–1446V. 

5. Karen Green, Alameda, California, 

Court of Federal Claims No: 15– 

1447V. 

6. Ruth Major, Linwood, New Jersey, 

Court of Federal Claims No: 15– 

1449V. 

7. Jamie Edwardson, Ketchikan, Alaska, 

Court of Federal Claims No: 15– 

1450V. 

8. Steven McKown and Tabitha 

McKown on behalf of C. M., Vienna, 

Virginia, Court of Federal Claims No: 

15–1451V. 

9. Leroy Albert Weinreich, Towson, 

Maryland, Court of Federal Claims 

No: 15–1454V. 

10. Stephanie Dimasi, Boston, 

Massachusetts, Court of Federal 

Claims No: 15–1455V. 

11. Olga Galvis, Dallas, Texas, Court of 

Federal Claims No: 15–1456V. 

12. Jason Johnson, Rock Island, Illinois, 

Court of Federal Claims No: 15– 

1457V. 

13. Tara Evans on behalf of B. E., Pagosa 

Springs, Colorado, Court of Federal 

Claims No: 15–1458V. 

14. Jennifer Hinkley on behalf of Charles 

Tuttle, Deceased, Richmond, Maine, 

Court of Federal Claims No: 15– 

1459V. 

15. Teresa Dianne Perdue on behalf of 

Robert Carlyle Perdue, Jr., Deceased, 

Boones Mill, Virginia, Court of 

Federal Claims No: 15–1460V. 

16. Odolphone Nored, Greenwood, 

Mississippi, Court of Federal Claims 

No: 15–1461V. 

17. Betsy Redfern, Boulder, Colorado, 

Court of Federal Claims No: 15– 

1462V. 

18. Marilyn Wenker, Brooklyn, New 

York, Court of Federal Claims No: 15– 

1463V. 

19. Jane Tougas, Marion, Massachusetts, 

Court of Federal Claims No: 15– 

1464V. 

20. Michelle Dalton on behalf of A. D., 

Phoenix, Arizona, Court of Federal 

Claims No: 15–1465V. 

21. Sarah Morris on behalf of G. M., 

Phoenix, Arizona, Court of Federal 

Claims No: 15–1466V. 

22. Kiasha Leitch on behalf of N. W., 

Brooklyn, New York, Court of Federal 

Claims No: 15–1467V. 

23. Kristal Grigg on behalf of N. G., 

Linwood, New Jersey, Court of 

Federal Claims No: 15–1468V. 

24. Susan Boyer, Merr, Indiana, Court of 

Federal Claims No: 15–1469V. 

25. Andrea Fuller on behalf of B. F., 

Phoenix, Arizona, Court of Federal 

Claims No: 15–1470V. 

26. Jennifer Leedy, Cherry Hill, New 

Jersey, Court of Federal Claims No: 

15–1471V. 

27. Shelly Plescia, Fountain Valley, 

California, Court of Federal Claims 

No: 15–1472V. 

28. Janet Cakir on behalf of C. A. C., 

Chapel Hill, North Carolina, Court of 

Federal Claims No: 15–1474V. 

29. Laurie Simmon, Boston, 

Massachusetts, Court of Federal 

Claims No: 15–1475V. 

30. Daryl Dawsonia, Boston, 

Massachusetts, Court of Federal 

Claims No: 15–1476V. 

31. Diane C. Perl, Hamburg, New York, 

Court of Federal Claims No: 15– 

1477V. 

32. Lou Ann Boersch, East Aurora, New 

York, Court of Federal Claims No: 15– 

1480V. 

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6280 Federal Register / Vol. 81, No. 24 / Friday, February 5, 2016 / Notices 

33. Adam Caselles and Lisa Caselles on 

behalf of N. A. C., Mission Viejo, 

California, Court of Federal Claims 

No: 15–1481V. 

34. Robert Lovejoy, Sarasota, Florida, 

Court of Federal Claims No: 15– 

1484V. 

35. Bettina McGill, Durham, North 

Carolina, Court of Federal Claims No: 

15–1485V. 

36. Andrew Potts, West Chester, 

Pennsylvania, Court of Federal Claims 

No: 15–1487V. 

37. Richard Hesse, Dallas, Texas, Court 

of Federal Claims No: 15–1488V. 

38. Matt Nichols, Fortville, Indiana, 

Court of Federal Claims No: 15– 

1490V. 

39. Phyllis Weir, Fairview, Texas, Court 

of Federal Claims No: 15–1491V. 

40. Jane M. Stuart, Livonia, Michigan, 

Court of Federal Claims No: 15– 

1493V. 

41. Carla Shiel and Mathew Shiel on 

behalf of Zara Antoinette Shiel, 

Deceased, Henderson, Nevada, Court 

of Federal Claims No: 15–1496V. 

42. Scott Marshall and Amy Marshall on 

behalf of H. M., Baraboo, Wisconsin, 

Court of Federal Claims No: 15– 

1497V. 

43. Candace M Thompson and Stephen 

E. Powell on behalf of A. H. P., Ocean 

City, New Jersey, Court of Federal 

Claims No: 15–1498V. 

44. Lee Patalowski, Lititz, Pennsylvania, 

Court of Federal Claims No: 15– 

1499V. 

45. Daniel Doherty, Long Island, New 

York, Court of Federal Claims No: 15– 

1500V. 

46. Doris Levitzki, Washington, District 

of Columbia, Court of Federal Claims 

No: 15–1502V. 

47. Ronald Belair, Bakersfield, 

California, Court of Federal Claims 

No: 15–1503V. 

48. Mario Reyes-Nieto, Riverside, 

California, Court of Federal Claims 

No: 15–1504V. 

49. Susan G. Webber, Woodstock, 

Georgia, Court of Federal Claims No: 

15–1506V. 

50. Monty Lowas, Manteca, California, 

Court of Federal Claims No: 15– 

1507V. 

51. Aileen Goner, Hallandale Beach, 

Florida, Court of Federal Claims No: 

15–1508V. 

52. David Parker, Philadelphia, 

Pennsylvania, Court of Federal Claims 

No: 15–1512V. 

53. Maxie Downs, Albertville, Alabama, 

Court of Federal Claims No: 15– 

1513V. 

54. Bryant Thompson, Seward, 

Nebraska, Court of Federal Claims No: 

15–1514V. 

55. Ian Brooks, Chicago, Illinois, Court 

of Federal Claims No: 15–1515V. 

56. Tonya Brock, Hixson, Tennessee, 

Court of Federal Claims No: 15– 

1516V. 

57. Edward Piotrowski, Itasca, Illinois, 

Court of Federal Claims No: 15– 

1517V. 

58. Jamie J. Dyson, Orlando, Florida, 

Court of Federal Claims No: 15– 

1518V. 

59. Eric G. Craver, Greensboro, North 

Carolina, Court of Federal Claims No: 

15–1519V. 

60. Tracy Mollica on behalf of A. M., 

Cranberry Township, Pennsylvania, 

Court of Federal Claims No: 15– 

1520V. 

61. Heidi White and David White on 

behalf of A. C. W., Exeter, New 

Hampshire, Court of Federal Claims 

No: 15–1521V. 

62. Stacia Wright, Beverly Hills, 

California, Court of Federal Claims 

No: 15–1523V. 

63. Gary Harris, San Antonio, Texas, 

Court of Federal Claims No: 15– 

1525V. 

64. Abigail Sims and Daniel Sims on 

behalf of A. E. S., Deceased, Oxford, 

Pennsylvania, Court of Federal Claims 

No: 15–1526V. 

65. John Homick and Rachel Homick on 

behalf of Z. H., Pittsburgh, 

Pennsylvania, Court of Federal Claims 

No: 15–1529V. 

66. Diane Streck, Scottsboro, Alabama, 

Court of Federal Claims No: 15– 

1530V. 

67. Carole Batson, Chicago, Illinois, 

Court of Federal Claims No: 15– 

1531V. 

68. Cathy Bruno on behalf of C B, 

Pittsburgh, Pennsylvania, Court of 

Federal Claims No: 15–1537V. 

69. Viola Bentley, Bethesda, Maryland, 

Court of Federal Claims No: 15– 

1540V. 

70. Elizabeth Ann Gray, Gallatin, 

Tennessee, Court of Federal Claims 

No: 15–1542V. 

71. Olivia Rodriguez, Philadelphia, 

Pennsylvania, Court of Federal Claims 

No: 15–1543V. 

72. Nancy Conley, Beverly Hills, 

California, Court of Federal Claims 

No: 15–1544V. 

73. David Merritt, Beverly Hills, 

California, Court of Federal Claims 

No: 15–1545V. 

74. Doris Steinbach, Athol, 

Massachusetts, Court of Federal 

Claims No: 15–1546V. 

75. Bernadette Dicianni and Michael 

Szilagyi on behalf of D. S., Chicago, 

Illinois, Court of Federal Claims No: 

15–1548V. 

76. Mona Holtry, Shippensburg, 

Pennsylvania, Court of Federal Claims 

No: 15–1551V. 

77. Karol Danner-Rieland, Boston, 

Massachusetts, Court of Federal 

Claims No: 15–1552V. 

78. Sherri Harrod on behalf of Jonathan 

Patton, St. Petersburg, Florida, Court 

of Federal Claims No: 15–1553V. 

79. John Cogliandro, Woburn, 

Massachusetts, Court of Federal 

Claims No: 15–1557V. 

80. Marcus C. Turner, Austin, Texas, 

Court of Federal Claims No: 15– 

1561V. 

81. David Landis, Cary, North Carolina, 

Court of Federal Claims No: 15– 

1562V. 

82. Vanessa Wood on behalf of A. W., 

Fort Dodge, Iowa, Court of Federal 

Claims No: 15–1568V. 

83. Glenda Ivy, Fredericksburg, Texas, 

Court of Federal Claims No: 15– 

1569V. 

84. Kimberly Bertolucci and Arthur 

Joseph McCauley, III on behalf of E. 

M., Napa, California, Court of Federal 

Claims No: 15–1573V. 

85. Carmen James on behalf of A J, 

Phoenix, Arizona, Court of Federal 

Claims No: 15–1576V. 

86. Hope Doucet on behalf of A. C., 

Deceased, Phoenix, Arizona, Court of 

Federal Claims No: 15–1577V. 

87. Michael DeAngelo, Laughlin, 

Nevada, Court of Federal Claims No: 

15–1578V. 

88. Laura McKenna, Abington, 

Pennsylvania, Court of Federal Claims 

No: 15–1580V. 

89. Stephen Lesicko, Dresher, 

Pennsylvania, Court of Federal Claims 

No: 15–1581V. 

90. Donna Soderman, Dresher, 

Pennsylvania, Court of Federal Claims 

No: 15–1582V. 

91. Gerry Ramey, Dresher, 

Pennsylvania, Court of Federal Claims 

No: 15–1585V. 

92. Stacey Nash, Oakland, California, 

Court of Federal Claims No: 15– 

1587V. 

93. Evelyn Bell, Philadelphia, 

Pennsylvania, Court of Federal Claims 

No: 15–1588V. 

94. Melvin Craig, Sarasota, Florida, 

Court of Federal Claims No: 15– 

1590V. 

[FR Doc. 2016–02245 Filed 2–4–16; 8:45 am] 

BILLING CODE 4165–15–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Meeting of the Advisory Committee on 

Minority Health; Correction 

AGENCY: Department of Health and 

Human Services, Office of the Secretary, 

Office of Minority Health. 

ACTION: Notice; correction. 

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