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Agency Information Collection Activities: Submission for OMB Review; Comment Request

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Centers for Medicare and 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 and Medicaid Services (CMS) (formerly known as 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.

(1) Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Medicare Health Survey (MHS); Form No.: CMS-10024 (OMB# 0938-0844)


This collection was published under CMS-10074/0938-NEW during the 60-day Federal Register notice comment period).

Use: The Centers for Medicare & Medicaid Services has developed a survey, the PHS, that is similar to the Health Outcomes Survey (HOS). The main purpose of the PHS is to collect health status information that may be used to adjust Medicare payments to PACE organizations. It has been successfully pilot-tested to assess response rates and accuracy of responses under different distribution approaches. The pilot test enabled CMS to select an approach whereby PACE enrollees will be sent surveys to fill out and can request assistance from family or professionals.; Frequency: Annually; Affected Public: Individuals or households, not-for-profit institutions; Number of Respondents: 8,550; Total Annual Responses: 5,814; Total Annual Hours: 1082.

(2) Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Long Term Care Awareness Project; Form No.: CMS-10041 (OMB# 0938-0825); Use: CMS-CBC needs to collect these data to pilot test a national campaign to educate current and future Medicare beneficiaries and their families about long term health care needs, as requested in the Presidential Initiative for Fiscal Year 2000 Budget. Project findings will be used to design and implement a nationwide campaign. Respondents will be from two groups: 55-70 year-olds and persons with disability who are 18-64 years of age; Frequency: Quarterly; Affected Public: Individuals or households; Number of Respondents: 2000; Total Annual Responses: 2000; Total Annual Hours: 667.

(3) Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Request for Certification, CMS-377 and the Ambulatory Surgical Center Survey Report Form, CMS-378 and CMS-R-0054 Supporting Regulations Contained in 42 CFR 416.1 thru 416.49; Form No.: CMS-0377/0378/R-0054 (OMB# 0938-0200); Use: The ASC request for certification form is utilized as an application for facilities wishing to participate in the Medicare program as an ASC. This form initiates the process of obtaining a decision as to whether the conditions of coverage are met. It also promotes data retrieval from the Online Data Input Edit (ODIE system, a subsystem of the Online Survey Certification and Report (OSCAR) system by CMS Regional Offices (RO)). The ASC report form is an instrument used by the State survey agency to record data collection in order to determine supplier compliance with individual conditions of coverage and to report it to the Federal government. The form is primarily a coding worksheet designed to facilitate data reduction and retrieval into the ODIE/OSCAR system at the HCFA ROs. This form includes basic information on compliance (i.e., met, not met and explanatory statements) and does not require any descriptive information regarding the survey activity itself.; Frequency: Annually; Affected Public: State, Local, or Tribal Government; Number of Respondents: 3,600; Total Annual Responses: 3,675; Total Annual Hours: 1,875. To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access CMS Web Site address at​regulations/​pra/​default.asp, or E-mail your request, including your address, phone number, OMB number, and CMS document identifier, to, or call the Reports Clearance Office on (410) 786-1326. Written comments and recommendations for the proposed information collections must be mailed within 30 days of this notice directly to the OMB desk officer: OMB Human Resources and Housing Branch, Attention: Brenda Aguilar, New Executive Office Building, Room 10235, Washington, DC 20503.

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Dated: January 2, 2003.

John P. Burke, III,

Paperwork Reduction Act Team Leader, CMS Reports Clearance Officer, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development and Issuances.

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[FR Doc. 03-483 Filed 1-9-03; 8:45 am]