Agency Information Collection Activities: Proposed Collection; Comment Request, 14517-14518 [2017-05535]
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Federal Register / Vol. 82, No. 53 / Tuesday, March 21, 2017 / Notices
language (e.g., Spanish, Arabic, Chinese,
Haitian Creole, Korean, Russian, and
Vietnamese) were used with consumers.
Form Number: CMS–10632 (OMB
control number: 0938—New);
Frequency: Occasionally; Affected
Public: Individuals or Households;
Number of Respondents: 3,460; Total
Annual Responses: 3,460; Total Annual
Hours: 1,176. (For policy questions
regarding this collection contact Ashley
Peddicord-Austin at 410–786–0757).
Dated: March 16, 2017.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2017–05555 Filed 3–20–17; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifiers: CMS–40B, CMS–43,
CMS–1763, CMS–10174, CMS–10215, CMS–
R–285]
Agency Information Collection
Activities: Proposed Collection;
Comment Request
Centers for Medicare &
Medicaid Services, HHS.
ACTION: Notice.
AGENCY:
The Centers for Medicare &
Medicaid Services (CMS) is announcing
an opportunity for the public to
comment on CMS’ intention to collect
information from the public. Under the
Paperwork Reduction Act of 1995 (the
PRA), federal agencies are required to
publish notice in the Federal Register
concerning each proposed collection of
information (including each proposed
extension or reinstatement of an existing
collection of information) and to allow
60 days for public comment on the
proposed action. Interested persons are
invited to send comments regarding our
burden estimates or any other aspect of
this collection of information, including
the necessity and utility of the proposed
information collection for the proper
performance of the agency’s functions,
the accuracy of the estimated burden,
ways to enhance the quality, utility, and
clarity of the information to be
collected, and the use of automated
collection techniques or other forms of
information technology to minimize the
information collection burden.
DATES: Comments must be received by
May 22, 2017.
ADDRESSES: When commenting, please
reference the document identifier or
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SUMMARY:
VerDate Sep<11>2014
16:47 Mar 20, 2017
Jkt 241001
OMB control number. To be assured
consideration, comments and
recommendations must be submitted in
any one of the following ways:
1. Electronically. You may send your
comments electronically to https://
www.regulations.gov. Follow the
instructions for ‘‘Comment or
Submission’’ or ‘‘More Search Options’’
to find the information collection
document(s) that are accepting
comments.
2. By regular mail. You may mail
written comments to the following
address: CMS, Office of Strategic
Operations and Regulatory Affairs,
Division of Regulations Development,
Attention: Document Identifier/OMB
Control Number lll, Room C4–26–
05, 7500 Security Boulevard, Baltimore,
Maryland 21244–1850.
To obtain copies of a supporting
statement and any related forms for the
proposed collection(s) summarized in
this notice, you may make your request
using one of following:
1. Access CMS’ Web site address at
https://www.cms.gov/Regulations-andGuidance/Legislation/Paperwork
ReductionActof1995/PRA-Listing.html.
2. Email your request, including your
address, phone number, OMB number,
and CMS document identifier, to
Paperwork@cms.hhs.gov.
3. Call the Reports Clearance Office at
(410) 786–1326.
FOR FURTHER INFORMATION CONTACT:
Reports Clearance Office at (410) 786–
1326.
SUPPLEMENTARY INFORMATION:
Contents
This notice sets out a summary of the
use and burden associated with the
following information collections. More
detailed information can be found in
each collection’s supporting statement
and associated materials (see
ADDRESSES).
CMS–40B Application for Enrollment in
Medicare the Medical Insurance Program
CMS–43 Application for Hospital Insurance
Benefits for Individuals with End Stage
Renal Disease
CMS–1763 Request for Termination of
Premium Hospital and Supplementary
Medical Insurance
CMS–10174 Collection of Prescription Drug
Event Data from Contracted Part D
Providers for Payment
CMS–10215 Medicaid Payment for
Prescription Drugs—Physicians and
Hospital Outpatient Departments
Collecting and Submitting Drug
Identifying Information to State
Medicaid Programs
CMS–R–285 Request for Retirement Benefit
Information
Under the PRA (44 U.S.C. 3501–
3520), federal agencies must obtain
PO 00000
Frm 00017
Fmt 4703
Sfmt 4703
14517
approval from the Office of Management
and Budget (OMB) for each collection of
information they conduct or sponsor.
The term ‘‘collection of information’’ is
defined in 44 U.S.C. 3502(3) and 5 CFR
1320.3(c) and includes agency requests
or requirements that members of the
public submit reports, keep records, or
provide information to a third party.
Section 3506(c)(2)(A) of the PRA
requires federal agencies to publish a
60-day notice in the Federal Register
concerning each proposed collection of
information, including each proposed
extension or reinstatement of an existing
collection of information, before
submitting the collection to OMB for
approval. To comply with this
requirement, CMS is publishing this
notice.
Information Collection
1. Type of Information Collection
Request: Extension without change of a
currently approved collection; Title of
Information Collection: Application for
Enrollment in Medicare the Medical
Insurance Program; Use: The CMS–40B
form is used to establish entitlement to
and enrollment in supplementary
medical insurance for beneficiaries who
already have Part A, but not Part B. The
form solicits information that is used to
determine enrollment for individuals
who meet the requirements in section
1836 of the Social Security Act as well
as the entitlement of the applicant or a
spouse regarding a benefit or annuity
paid by the Social Security
Administration or the Office of
Personnel Management for premium
deduction purposes. The Social Security
Administration will use the collected
information to establish Part B
enrollment. Form Number: CMS–40B
(OMB control number: 0938–1230);
Frequency: Once; Affected Public:
Individuals or households; Number of
Respondents: 200,000; Total Annual
Responses: 200,000; Total Annual
Hours: 50,000. (For policy questions
regarding this collection contact Carla
Patterson at 410–786–8911.)
2. Type of Information Collection
Request: Extension without change of a
currently approved collection; Title of
Information Collection: Application for
Hospital Insurance Benefits for
Individuals with End Stage Renal
Disease; Use: The CMS–43 application
is used (in conjunction with CMS–2728)
to establish entitlement to, and
enrollment in, Medicare Part A (and
Part B) for individuals with end stage
renal disease. The application is
completed by a Social Security
Administration (SSA) claims
representative or field representative
using information provided by the
E:\FR\FM\21MRN1.SGM
21MRN1
mstockstill on DSK3G9T082PROD with NOTICES
14518
Federal Register / Vol. 82, No. 53 / Tuesday, March 21, 2017 / Notices
individual during an interview. The
CMS–43 application follows the
questions and requirements used by
SSA to determine Title II eligibility.
This is done not only for consistency
purposes, but because certain Title II
and Title XVIII insured status and
relationship requirements must be met
in order to qualify for Medicare under
the end stage renal disease provisions.
Form Number: CMS–43 (OMB control
number: 0938–0800); Frequency: Once;
Affected Public: Individuals or
households; Number of Respondents:
25,000; Total Annual Responses:
25,000; Total Annual Hours: 10,400.
(For policy questions regarding this
collection contact Carla Patterson at
410–786–8911.)
3. Type of Information Collection
Request: Extension without change of a
currently approved collection; Title of
Information Collection: Request for
Termination of Premium Hospital and
Supplementary Medical Insurance; Use:
The CMS–1763 form provides us and
the Social Security Administration
(SSA) with the enrollee’s request for
termination of Part B, Part A or both
Part B and A premium coverage. The
form is completed by an SSA claims or
field representative using information
provided by the Medicare enrollee
during an interview. The purpose of the
form is to provide to the enrollee with
a standardized format to request
termination of Part B, Part A premium
coverage or both, explain why the
enrollee wishes to terminate such
coverage, and to acknowledge that the
ramifications of the decision are
understood. Form Number: CMS–1763
(OMB control number: 0938–0025);
Frequency: Once; Affected Public:
Individuals or households; Number of
Respondents: 101,000; Total Annual
Responses: 101,000; Total Annual
Hours: 16,867. (For policy questions
regarding this collection contact Carla
Patterson at 410–786–8911.)
4. Type of Information Collection
Request: Revision of a currently
approved collection; Title of
Information Collection: Collection of
Prescription Drug Event Data from
Contracted Part D Providers for
Payment; Use: The collected
information is used primarily for
payment, but is also used for claim
validation as well as for other legislated
functions such as quality monitoring,
program integrity, and oversight. Form
Number: CMS–10174 (OMB control
number: 0938–0982); Frequency:
Monthly; Affected Public: Business or
other for-profits and Not-for-profit
institutions; Number of Respondents:
779; Total Annual Responses:
1,409,828,464; Total Annual Hours:
VerDate Sep<11>2014
16:47 Mar 20, 2017
Jkt 241001
2,820. (For policy questions regarding
this collection contact Ivan Iveljic at
410–786–3312.)
5. Type of Information Collection
Request: Extension without change of a
currently approved collection; Title of
Information Collection: Medicaid
Payment for Prescription Drugs—
Physicians and Hospital Outpatient
Departments Collecting and Submitting
Drug Identifying Information to State
Medicaid Programs; Use: States are
required to provide for the collection
and submission of utilization data for
certain physician-administered drugs in
order to receive federal financial
participation for these drugs.
Physicians, serving as respondents to
states, submit National Drug Code
numbers and utilization information for
‘‘J’’ code physician-administered drugs
so that the states will have sufficient
information to collect drug rebate
dollars. Form Number: CMS–10215
(OMB control number: 0938–1026);
Frequency: Weekly; Affected Public:
Business or other for-profits and Notfor-profit institutions); Number of
Respondents: 20,000; Total Annual
Responses: 3,910,000; Total Annual
Hours: 16,227. (For policy questions
regarding this collection contact Lisa
Ferrandi at 410–786–5445.)
6. Type of Information Collection
Request: Extension without change of a
currently approved collection; Title of
Information Collection: Request for
Retirement Benefit Information; Use:
Section 1818(d)(5) of the Social Security
Act provides that former state and local
government employees (who are age 65
or older, have been entitled to Premium
Part A for at least 7 years, and did not
have the premium paid for by a state, a
political subdivision of a state, or an
agency or instrumentality of one or
more states or political subdivisions)
may have the Part A premium reduced
to zero. These individuals must also
have 10 years of employment with the
state or local government employer or a
combination of 10 years of employment
with a state or local government
employer and a non-government
employer. The CMS–R–285 form is an
essential part of the process of
determining whether an individual
qualifies for the premium reduction.
The Social Security Administration will
use this information to help determine
whether a beneficiary meets the
requirements for reduction of the Part A
premium. Form Number: CMS–R–285
(OMB control number: 0938–0769);
Frequency: Once; Affected Public: State,
Local, or Tribal Governments; Number
of Respondents: 500; Total Annual
Responses: 500; Total Annual Hours:
125. (For policy questions regarding this
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Frm 00018
Fmt 4703
Sfmt 4703
collection contact Carla Patterson at
410–786–8911.)
Dated: March 16, 2017.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2017–05535 Filed 3–20–17; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Food and Drug Administration
[Docket No. FDA–2017–N–1066]
Agency Information Collection
Activities; Proposed Collection;
Comment Request; Annual Reporting
for Custom Device Exemption
AGENCY:
Food and Drug Administration,
HHS.
ACTION:
Notice.
The Food and Drug
Administration (FDA) is announcing an
opportunity for public comment on the
proposed collection of certain
information by the Agency. Under the
Paperwork Reduction Act of 1995 (the
PRA), Federal Agencies are required to
publish notice in the Federal Register
concerning each proposed collection of
information, including each proposed
extension of an existing collection of
information, and to allow 60 days for
public comment in response to the
notice. This notice solicits comments on
information collection associated with
the annual reporting for custom devices.
DATES: Submit either electronic or
written comments on the collection of
information by May 22, 2017.
ADDRESSES: You may submit comments
as follows:
SUMMARY:
Electronic Submissions
Submit electronic comments in the
following way:
• Federal eRulemaking Portal:
https://www.regulations.gov. Follow the
instructions for submitting comments.
Comments submitted electronically,
including attachments, to https://
www.regulations.gov will be posted to
the docket unchanged. Because your
comment will be made public, you are
solely responsible for ensuring that your
comment does not include any
confidential information that you or a
third party may not wish to be posted,
such as medical information, your or
anyone else’s Social Security number, or
confidential business information, such
as a manufacturing process. Please note
that if you include your name, contact
E:\FR\FM\21MRN1.SGM
21MRN1
Agencies
[Federal Register Volume 82, Number 53 (Tuesday, March 21, 2017)]
[Notices]
[Pages 14517-14518]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-05535]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifiers: CMS-40B, CMS-43, CMS-1763, CMS-10174, CMS-10215,
CMS-R-285]
Agency Information Collection Activities: Proposed Collection;
Comment Request
AGENCY: Centers for Medicare & Medicaid Services, HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: The Centers for Medicare & Medicaid Services (CMS) is
announcing an opportunity for the public to comment on CMS' intention
to collect information from the public. Under the Paperwork Reduction
Act of 1995 (the PRA), federal agencies are required to publish notice
in the Federal Register concerning each proposed collection of
information (including each proposed extension or reinstatement of an
existing collection of information) and to allow 60 days for public
comment on the proposed action. Interested persons are invited to send
comments regarding our burden estimates or any other aspect of this
collection of information, including the necessity and utility of the
proposed information collection for the proper performance of the
agency's functions, the accuracy of the estimated burden, ways to
enhance the quality, utility, and clarity of the information to be
collected, and the use of automated collection techniques or other
forms of information technology to minimize the information collection
burden.
DATES: Comments must be received by May 22, 2017.
ADDRESSES: When commenting, please reference the document identifier or
OMB control number. To be assured consideration, comments and
recommendations must be submitted in any one of the following ways:
1. Electronically. You may send your comments electronically to
https://www.regulations.gov. Follow the instructions for ``Comment or
Submission'' or ``More Search Options'' to find the information
collection document(s) that are accepting comments.
2. By regular mail. You may mail written comments to the following
address: CMS, Office of Strategic Operations and Regulatory Affairs,
Division of Regulations Development, Attention: Document Identifier/OMB
Control Number ___, Room C4-26-05, 7500 Security Boulevard, Baltimore,
Maryland 21244-1850.
To obtain copies of a supporting statement and any related forms
for the proposed collection(s) summarized in this notice, you may make
your request using one of following:
1. Access CMS' Web site address at https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.
2. Email your request, including your address, phone number, OMB
number, and CMS document identifier, to Paperwork@cms.hhs.gov.
3. Call the Reports Clearance Office at (410) 786-1326.
FOR FURTHER INFORMATION CONTACT: Reports Clearance Office at (410) 786-
1326.
SUPPLEMENTARY INFORMATION:
Contents
This notice sets out a summary of the use and burden associated
with the following information collections. More detailed information
can be found in each collection's supporting statement and associated
materials (see ADDRESSES).
CMS-40B Application for Enrollment in Medicare the Medical Insurance
Program
CMS-43 Application for Hospital Insurance Benefits for Individuals
with End Stage Renal Disease
CMS-1763 Request for Termination of Premium Hospital and
Supplementary Medical Insurance
CMS-10174 Collection of Prescription Drug Event Data from Contracted
Part D Providers for Payment
CMS-10215 Medicaid Payment for Prescription Drugs--Physicians and
Hospital Outpatient Departments Collecting and Submitting Drug
Identifying Information to State Medicaid Programs
CMS-R-285 Request for Retirement Benefit Information
Under the PRA (44 U.S.C. 3501-3520), federal agencies must obtain
approval from the Office of Management and Budget (OMB) for each
collection of information they conduct or sponsor. The term
``collection of information'' is defined in 44 U.S.C. 3502(3) and 5 CFR
1320.3(c) and includes agency requests or requirements that members of
the public submit reports, keep records, or provide information to a
third party. Section 3506(c)(2)(A) of the PRA requires federal agencies
to publish a 60-day notice in the Federal Register concerning each
proposed collection of information, including each proposed extension
or reinstatement of an existing collection of information, before
submitting the collection to OMB for approval. To comply with this
requirement, CMS is publishing this notice.
Information Collection
1. Type of Information Collection Request: Extension without change
of a currently approved collection; Title of Information Collection:
Application for Enrollment in Medicare the Medical Insurance Program;
Use: The CMS-40B form is used to establish entitlement to and
enrollment in supplementary medical insurance for beneficiaries who
already have Part A, but not Part B. The form solicits information that
is used to determine enrollment for individuals who meet the
requirements in section 1836 of the Social Security Act as well as the
entitlement of the applicant or a spouse regarding a benefit or annuity
paid by the Social Security Administration or the Office of Personnel
Management for premium deduction purposes. The Social Security
Administration will use the collected information to establish Part B
enrollment. Form Number: CMS-40B (OMB control number: 0938-1230);
Frequency: Once; Affected Public: Individuals or households; Number of
Respondents: 200,000; Total Annual Responses: 200,000; Total Annual
Hours: 50,000. (For policy questions regarding this collection contact
Carla Patterson at 410-786-8911.)
2. Type of Information Collection Request: Extension without change
of a currently approved collection; Title of Information Collection:
Application for Hospital Insurance Benefits for Individuals with End
Stage Renal Disease; Use: The CMS-43 application is used (in
conjunction with CMS-2728) to establish entitlement to, and enrollment
in, Medicare Part A (and Part B) for individuals with end stage renal
disease. The application is completed by a Social Security
Administration (SSA) claims representative or field representative
using information provided by the
[[Page 14518]]
individual during an interview. The CMS-43 application follows the
questions and requirements used by SSA to determine Title II
eligibility. This is done not only for consistency purposes, but
because certain Title II and Title XVIII insured status and
relationship requirements must be met in order to qualify for Medicare
under the end stage renal disease provisions. Form Number: CMS-43 (OMB
control number: 0938-0800); Frequency: Once; Affected Public:
Individuals or households; Number of Respondents: 25,000; Total Annual
Responses: 25,000; Total Annual Hours: 10,400. (For policy questions
regarding this collection contact Carla Patterson at 410-786-8911.)
3. Type of Information Collection Request: Extension without change
of a currently approved collection; Title of Information Collection:
Request for Termination of Premium Hospital and Supplementary Medical
Insurance; Use: The CMS-1763 form provides us and the Social Security
Administration (SSA) with the enrollee's request for termination of
Part B, Part A or both Part B and A premium coverage. The form is
completed by an SSA claims or field representative using information
provided by the Medicare enrollee during an interview. The purpose of
the form is to provide to the enrollee with a standardized format to
request termination of Part B, Part A premium coverage or both, explain
why the enrollee wishes to terminate such coverage, and to acknowledge
that the ramifications of the decision are understood. Form Number:
CMS-1763 (OMB control number: 0938-0025); Frequency: Once; Affected
Public: Individuals or households; Number of Respondents: 101,000;
Total Annual Responses: 101,000; Total Annual Hours: 16,867. (For
policy questions regarding this collection contact Carla Patterson at
410-786-8911.)
4. Type of Information Collection Request: Revision of a currently
approved collection; Title of Information Collection: Collection of
Prescription Drug Event Data from Contracted Part D Providers for
Payment; Use: The collected information is used primarily for payment,
but is also used for claim validation as well as for other legislated
functions such as quality monitoring, program integrity, and oversight.
Form Number: CMS-10174 (OMB control number: 0938-0982); Frequency:
Monthly; Affected Public: Business or other for-profits and Not-for-
profit institutions; Number of Respondents: 779; Total Annual
Responses: 1,409,828,464; Total Annual Hours: 2,820. (For policy
questions regarding this collection contact Ivan Iveljic at 410-786-
3312.)
5. Type of Information Collection Request: Extension without change
of a currently approved collection; Title of Information Collection:
Medicaid Payment for Prescription Drugs--Physicians and Hospital
Outpatient Departments Collecting and Submitting Drug Identifying
Information to State Medicaid Programs; Use: States are required to
provide for the collection and submission of utilization data for
certain physician-administered drugs in order to receive federal
financial participation for these drugs. Physicians, serving as
respondents to states, submit National Drug Code numbers and
utilization information for ``J'' code physician-administered drugs so
that the states will have sufficient information to collect drug rebate
dollars. Form Number: CMS-10215 (OMB control number: 0938-1026);
Frequency: Weekly; Affected Public: Business or other for-profits and
Not-for-profit institutions); Number of Respondents: 20,000; Total
Annual Responses: 3,910,000; Total Annual Hours: 16,227. (For policy
questions regarding this collection contact Lisa Ferrandi at 410-786-
5445.)
6. Type of Information Collection Request: Extension without change
of a currently approved collection; Title of Information Collection:
Request for Retirement Benefit Information; Use: Section 1818(d)(5) of
the Social Security Act provides that former state and local government
employees (who are age 65 or older, have been entitled to Premium Part
A for at least 7 years, and did not have the premium paid for by a
state, a political subdivision of a state, or an agency or
instrumentality of one or more states or political subdivisions) may
have the Part A premium reduced to zero. These individuals must also
have 10 years of employment with the state or local government employer
or a combination of 10 years of employment with a state or local
government employer and a non-government employer. The CMS-R-285 form
is an essential part of the process of determining whether an
individual qualifies for the premium reduction. The Social Security
Administration will use this information to help determine whether a
beneficiary meets the requirements for reduction of the Part A premium.
Form Number: CMS-R-285 (OMB control number: 0938-0769); Frequency:
Once; Affected Public: State, Local, or Tribal Governments; Number of
Respondents: 500; Total Annual Responses: 500; Total Annual Hours: 125.
(For policy questions regarding this collection contact Carla Patterson
at 410-786-8911.)
Dated: March 16, 2017.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and
Regulatory Affairs.
[FR Doc. 2017-05535 Filed 3-20-17; 8:45 am]
BILLING CODE 4120-01-P