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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: Extension of a currently approved collection; Title of Information Collection: The Financial Statement of Debtor and Supporting Regulations in 42 CF Section 405.376; Form No.: CMS-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, individuals or households; Number of Respondents: 500; Total Annual Responses: 500; Total Annual Hours: 1,000.

2. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Clinical Laboratory Improvement Amendments Application Form and Supporting Regulations in 42 CFR 493.1-.2001; Form No.: CMS-116 (OMB# 0938-0581); Use: Clinical Laboratory Certification—The application must be completed by entities performing laboratory testing on human specimens for diagnostic or treatment purposes. This information is vital to the certification process.; Frequency: Bi-annually; Affected Public: Business or other for-profit, not-for-profit institutions, Federal Government, and State, Local, or Tribal Government; Number of Respondents: 16,000; Total Annual Responses: 16,000; Total Annual Hours: 20,000.

3. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Information Collection Requirements Referenced in 42 CFR 424.57; Additional DMEPOS Supplier Standards; Form No.: CMS-R-215 (OMB# 0938-0717); Use: Respondents will be suppliers of Durable Medicare Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). CMS needs documentation that the DMEPOS supplier has advised beneficiaries that they may either rent or purchase inexpensive or routinely purchased equipment and about the purchase option for capped rental equipment. This is needed to determine if the supplier has met the supplier standards.; Frequency: On Occasion and Annually; Affected Public: Business or other for-profit and not-for-profit institutions; Number of Respondents: 63,986; Total Annual Responses: 35,000; Total Annual Hours: 280,000.

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/​, 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: Christopher Martin, New Executive Office Building, Room 10235, Washington, DC 20503.

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Dated: July 2, 2004.

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. 04-15814 Filed 7-15-04; 8:45 am]