Skip to Content


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

Document Details

Information about this document as published in the Federal Register.

Document Statistics
Document page views are updated periodically throughout the day and are cumulative counts for this document including its time on Public Inspection. Counts are subject to sampling, reprocessing and revision (up or down) throughout the day.
Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

Start Preamble


Centers for Medicare & 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 & Medicaid Services (CMS), 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 function; (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: Clinical Laboratory Improvement Amendments (CLIA) Application Form and Supporting Regulations in 42 CFR 493.1-.2001Medicare/Medicaid Psychiatric Hospital Survey Data; Use: The application must be completed by entities performing laboratory's testing specimens for diagnostic or treatment purposes. This information is vital to the certification process. Form Number: CMS-116 (OMB#: 0938-0581); Frequency: Biennially and Occasionally; Affected Public: Private Sector: Business or other for-profits and Not-for-profit institutions; Number of Respondents: 219,000; Total Annual Responses: 31,520; Total Annual Hours: 23,640. (For policy questions regarding this collection contact Sheila Ward at 410-786-3115. For all other issues call 410-786-1326.)

2. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Hospice Request for Certification in the Medicare Program; Use: The Hospice Request for Certification Form is the identification and screening form used to initiate the certification process and to determine if the provider has sufficient personnel to participate in the Medicare program. Form Number: CMS-417 (OMB#: 0938-0313); Frequency: Annually; Affected Public: Private Sector: Business or other for-profits; Number of Respondents: 3,494; Total Annual Responses: 3,494; Total Annual Hours: 594. (For policy questions regarding this collection contact Debbie Terkay at 410-786-6835. For all other issues call 410-786-1326.)

To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access CMS Web site address at​PaperworkReductionActof1995, 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.

To be assured consideration, comments and recommendations for the proposed information collections must be received by the OMB desk officer at the address below, no later than 5 p.m. on December 27, 2010.

OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk Officer,

Fax Number: (202) 395-6974.


Start Signature

Dated: November 18, 2010.

Michelle Shortt,

Director, Regulations Development Group, Office of Strategic Operations and Regulatory Affairs.

End Signature End Preamble

[FR Doc. 2010-29718 Filed 11-24-10; 8:45 am]