[Federal Register Volume 61, Number 128 (Tuesday, July 2, 1996)]
[Notices]
[Pages 34437-34438]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-16844]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

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 summaries 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: Reinstatement, without 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Information Collection 
Requirements in 42 CFR 473.18 (a) and (b), 473.34 (a) and (b), 473.36 
(a) and (b), and 473.42 (a), Peer Review Organization (PRO) 
Reconsideration and Appeals; Form No.: HCFA-R-72; Use: These 
regulations contain procedures for PRO's to use in reconsideration of 
initial determinations. The information requirements contained in these 
regulations are on PROs to provide information to parties requesting a 
reconsideration review. These parties will use the information as 
guidelines for appeal rights in instances where issues are still in 
dispute; Frequency: On occasion; Affected Public: Business or other for 
profit; Number of Respondents: 53; Total Annual Responses: 15,670; 
Total Annual Hours: 3,578.
    2. Type of Information Collection Request: Reinstatement, without 
change, of previously approved collection for

[[Page 34438]]

which approval has expired; Title of Information Collection: Request 
for Enrollment in Supplementary Medical Insurance; Form No.: HCFA-4040; 
Use: The HCFA-4040 is used to establish entitlement to Supplementary 
Medical Insurance by Beneficiaries not eligible under Part A of Title 
XVIII or Title II of the Social Security Act. The HCFA-4040SP is the 
Spanish edition of this form; Frequency: One time only; Affected 
Public: Individuals and households, Federal government, State, local, 
or tribal governments; Number of Respondents: 10,000; Total Annual 
Responses: 10,000; Total Annual Hours: 2,500.
    3. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Request for 
Certification as a Rural Health Clinic, Rural Health Clinic Survey 
Report Form; Form No.: HCFA-29, 30; Use: The form HCFA-29 ``Request for 
Certification as a Rural Health Clinics'' is used by facilities to 
apply to participate in the Medicare program. The form HCFA-30 ``Rural 
Health Clinic Survey Report Form, is used by State survey agencies to 
record data needed to determine compliance with the Federal 
requirements; Frequency: Annually; Affected Public: State, local or 
tribal governments; Number of Respondents: 390; Total Annual Responses: 
390; Total Annual Hours: 682.
    4. Type of Information Collection Request: Reinstatement, without 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Quarterly Showing; Form No.: 
HCFA-R-41; Use: This form is used by State Medicaid agencies to list 
participating health care facilities and the dates the State agencies 
reviewed the facilities. The lists are required to assure the existence 
of an effective utilization (of services) control program, as required 
by law and regulation, to avoid a penalty; Frequency: Quarterly; 
Affected Public: State, local or tribal governments; Number of 
Respondents: 47; Total Annual Responses: 188; Total Annual Hours: 
9,212.
    5. Type of Information Collection Request: Reinstatement, without 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Quarterly Showing Validation 
Survey; Form No.: HCFA-9050; Use: Reporting entities may be required to 
submit lists of Medicaid beneficiaries residing in a select number of 
institutions. State Medicaid agencies may also be required to submit 
procedures for conducting inspection of care reviews and other 
documentation necessary to validate the Quarterly Showing reports. The 
listings are required to determine those patients for which the State 
is currently responsible for their care. This part of the operation to 
determine that states have an effective utilization control program; 
Frequency: Annually; Affected Public: State, local or tribal 
governments; Number of Respondents: 47; Total Annual Responses: 8; 
Total Annual Hours: 376.
    6. Type of Information Collection Request: Reinstatement, with 
change, of previously approved collection for which approval has 
expired; Title of Information Collection: Medicare Managed Care 
Disenrollment Form; Form No.: HCFA-566; Use: This form is used to 
process a beneficiaries request of disenrollment action from a health 
maintenance organization or competitive medical plan and to update the 
beneficiaries' health insurance master record; Frequency: On occasion; 
Affected Public: Individuals and households, Business or other for 
profit, not for profit institutions, Federal government, State, local, 
or tribal governments; Number of Respondents: 24,000; Total Annual 
Responses: 24,000; Total Annual Hours: 792.
    7. Type of Information Collection Request: New collection; Title of 
Information Collection: ``Maximizing the Effective Use of Telemedicine: 
A study of the Effects, Cost Effectiveness and Utilization Patterns of 
Consultations via Telemedicine.''; Form No.: HCFA-R-197; Use: The major 
objective of this study is to evaluate the medical and cost 
effectiveness of three different categories of telemedicine services; 
Frequency: Other (periodically); Affected Public: Individuals and 
households, Business or other for profit, not for profit institutions; 
Number of Respondents: 1819; Total Annual Responses: 11,095; Total 
Annual Hours: 1,564.
    8. Type of Information Collection Request: Revision of a currently 
approved collection; Title of Information Collection: Business Proposal 
Formats for Utilization and Quality Control Peer Review Organizations 
(PROs); Form No.: HCFA-718-721; Use: Submission of proposal information 
by current PROs and other bidders, according to the business proposal 
instructions, will satisfy HCFA's need for consistent, and verifiable 
data with which to validate contract proposals; Frequency: Other (Tri-
annually); Affected Public: Business or other for profit, not for 
profit institutions; Number of Respondents: 20; Total Annual Responses: 
23; Total Annual Hours: 450.
    9. Type of Information Collection Request: Reinstatement, without 
change, of a previously approved collection for which approval has 
expired; Title of Information Collection: Request for Accelerated 
Payments; Form No.: HCFA-9042; Use: These forms are used by fiscal 
intermediaries to access a provider's eligibility for accelerated 
payments. Such payment is granted if there is an unusual delay in 
processing bills. Frequency: On occasion; Affected Public: Business or 
other for-profit and Not for-profit institutions; Number of 
Respondents: 854; Total Annual Responses: 854; Total Annual Hours 
Requested: 427.
    To obtain copies of the supporting statement for the proposed 
paperwork collections referenced above, access HCFA's WEB SITE ADDRESS 
at http://www.hcfa.gov , or to obtain the supporting statement and any 
related forms, E-mail your request, including your address and phone 
number, to P<a href="/cdn-cgi/l/email-protection#e081908592978f928ba088838681ce878f96"><span class="__cf_email__" data-cfemail="2445544156534b564f644c4742450a434b52">[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 Financial and Human Resources, 
Management Planning and Analysis Staff, Attention: John Burke, Room C2-
26-17, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

    Dated: June 25, 1996.
Kathleen B. Larson,
Director, Management Planning and Analysis Staff, Office of Financial 
and Human Resources, Health Care Financing Administration.
[FR Doc. 96-16844 Filed 7-1-96; 8:45 am]
BILLING CODE 4120-03-P


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