Agency Information Collection Activities: Submission for OMB Review; Comment Request, 21198-21199 [05-8162]
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21198
Federal Register / Vol. 70, No. 78 / Monday, April 25, 2005 / Notices
Brule, Pine Ridge, Rosebud, Standing
Rock and Yankton Indian Reservations;
any land held in trust by the United
States for an Indian tribe, and any other
areas which are ‘‘Indian country’’
within the meaning of 18 U.S.C. 1151.
C. Requesting a Hearing
Any request for a public hearing shall
include: (1) The name, address, and
telephone number of the individual,
organization, or other entity requesting
a hearing; (2) a brief statement of the
requester’s interest in the RA’s
determination and of information that
he/she intends to submit at such
hearing; and (3) the signature of the
requester or responsible official, if made
on behalf of an organization or other
entity.
Notice of any hearing shall be given
not less than fifteen (15) days prior to
the time scheduled for the hearing, and
will be made by the RA in the Federal
Register and newspapers of general
circulation in the State. A notice will
also be sent to both the person(s)
requesting the hearing and the State.
The hearing notice will include a
statement of purpose, information
regarding time and location, and the
address and telephone number where
interested persons may obtain further
information. The RA will issue a final
determination upon review of the
hearing record.
Frivolous or insubstantial requests for
a hearing may be denied by the RA.
However, if a substantial request is
made within thirty (30) days after this
notice, a public hearing will be held.
Please bring this notice to the
attention of any persons known by you
to have an interest in this
determination.
Dated: April 15, 2005.
Kerrigan G. Clough,
Deputy Regional Administrator, Region 8.
[FR Doc. 05–8192 Filed 4–22–05; 8:45 am]
BILLING CODE 6560–50–P
FEDERAL RESERVE SYSTEM
rmajette on DSK29S0YB1PROD with NOTICES
Formations of, Acquisitions by, and
Mergers of Bank Holding Companies
The companies listed in this notice
have applied to the Board for approval,
pursuant to the Bank Holding Company
Act of 1956 (12 U.S.C. 1841 et seq.)
(BHC Act), Regulation Y (12 CFR Part
225), and all other applicable statutes
and regulations to become a bank
holding company and/or to acquire the
assets or the ownership of, control of, or
the power to vote shares of a bank or
bank holding company and all of the
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14:51 Oct 19, 2009
Jkt 220001
banks and nonbanking companies
owned by the bank holding company,
including the companies listed below.
The applications listed below, as well
as other related filings required by the
Board, are available for immediate
inspection at the Federal Reserve Bank
indicated. The application also will be
available for inspection at the offices of
the Board of Governors. Interested
persons may express their views in
writing on the standards enumerated in
the BHC Act (12 U.S.C. 1842(c)). If the
proposal also involves the acquisition of
a nonbanking company, the review also
includes whether the acquisition of the
nonbanking company complies with the
standards in section 4 of the BHC Act
(12 U.S.C. 1843). Unless otherwise
noted, nonbanking activities will be
conducted throughout the United States.
Additional information on all bank
holding companies may be obtained
from the National Information Center
website at www.ffiec.gov/nic/.
Unless otherwise noted, comments
regarding each of these applications
must be received at the Reserve Bank
indicated or the offices of the Board of
Governors not later than May 20, 2005.
A. Federal Reserve Bank of
Richmond (A. Linwood Gill, III, Vice
President) 701 East Byrd Street,
Richmond, Virginia 23261-4528:
1. Square 1 Financial, Inc., Pinehurst,
North Carolina; to become a bank
holding company by acquiring 100
percent of the voting shares of Square 1
Bank, Durham, North Carolina, in
organization.
B. Federal Reserve Bank of Atlanta
(Andre Anderson, Vice President) 1000
Peachtree Street, N.E., Atlanta, Georgia
30303:
1. FirstFed Bancorp, Inc. Employee
Stock Ownership Pan, Bessemer,
Alabama; to become a bank holding
company by acquiring 32 percent of the
voting shares of FirstFed Bancorp, Inc.,
Bessemer, Alabama, and thereby
indirectly acquire voting shares of First
Financial Bank, Bessemer, Alabama.
2. Habersham Bancorp, Cornelia,
Georgia; to acquire 100 percent of the
voting shares of Liberty Bank & Trust,
Toccoa, Georgia.
C. Federal Reserve Bank of St. Louis
(Glenda Wilson, Community Affairs
Officer) 411 Locust Street, St. Louis,
Missouri 63166-2034:
1. Mercantile Bancorp, Inc., Quincy,
Illinois; to acquire an additional 7.25
percent, for a total of 21 percent, of the
voting shares of Northstar Bancshares,
Inc., Kansas City, Missouri, and thereby
indirectly acquire additional voting
shares of Northstar Bank, National
Association, Kansas City, Missouri.
PO 00000
Frm 00026
Fmt 4703
Sfmt 4703
Board of Governors of the Federal Reserve
System, April 19, 2005.
Robert deV. Frierson,
Deputy Secretary of the Board.
[FR Doc. 05–8153 Filed 4–22–05; 8:45 am]
BILLING CODE 6210–01–S
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifier: CMS–287, CMS–1771,
CMS–R–71, CMS–222]
Agency Information Collection
Activities: Submission for OMB
Review; Comment Request
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 Request:
Revision of a currently approved
collection; Title of Information
Collection: Home Office Cost Statement
and Supporting Regulations in 42 CFR
413.17 and 413.20; Use: The Home
Office Cost Statement is filed annually
by Chain Home Offices to report the
information necessary for the
determination of Medicare
reimbursement to components of chain
organizations. Many providers of service
participating in Medicare are
reimbursed, at least partially, on the
basis of the lesser of reasonable cost or
customary services for services
furnished to eligible beneficiaries. When
providers obtain services, supplies or
facilities from an organization related to
the provider by common ownership or
control, 42 CFR 413.17 requires that the
provider include in its costs, the costs
incurred by the related organization in
AGENCY:
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25APN1
rmajette on DSK29S0YB1PROD with NOTICES
Federal Register / Vol. 70, No. 78 / Monday, April 25, 2005 / Notices
furnishing such services, supplies or
facilities. Revisions to this form include
the addition of columns for more
detailed reporting and the elimination
of other columns that were deemed
unnecessary; Form Number: CMS–287
(OMB # 0938–0202); Frequency:
Annually; Affected Public: Not-for-profit
institutions and Business or other forprofit; Number of Respondents: 1,231;
Total Annual Responses: 1,231; Total
Annual Hours: 573,646.
2. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Attending
Physicians Statement and
Documentation of a Medicare
Emergency and Supporting Regulations
in 42 CFR 424.103; Use: 42 CFR
424.103(b) requires that before a
nonparticipating hospital may be paid
for emergency services rendered to a
Medicare beneficiary, a statement must
be submitted that is sufficiently
comprehensive to support that an
emergency existed. Form CMS–1771
contains a series of questions relating to
the medical necessity of the emergency.
The attending physician must attest that
the hospitalization was required under
the regulatory emergency definition (42
CFR 424.101 attached) and give clinical
documentation to support the claim;
Form Number: CMS–1771 (OMB #:
0938–0023); Frequency: Reporting—On
occasion; Affected Public: Business or
other for-profit; Number of
Respondents: 200; Total Annual
Responses: 200; Total Annual Hours:
50.
3. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Quality
Improvement Organization (QIO)
Assumption of Responsibilities and
Supporting Regulations in 42 CFR
412.44, 412.46, 431.630, 476.71, 476.73,
476.74, and 476.78; Use: The Peer
Review Improvement Act of 1982
amended Title XI of the Social Security
Act to create the Utilization and Quality
Control Peer Review Organization (PRO)
program which replaces the Professional
Standards Review Organization (PSRO)
program and streamlines peer review
activities. The term PRO has been
renamed Quality Improvement
Organization (QIO). This collection
describes the review functions to be
performed by the QIO. It outlines
relationships among QIOs, providers,
practitioners, beneficiaries,
intermediaries, and carriers; Form
Numbers: CMS–R–71 (OMB # 0938–
0445); Frequency: Recordkeeping and
Third Party Disclosure, as needed;
Affected Public: Business or other for-
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14:51 Oct 19, 2009
Jkt 220001
profit; Number of Respondents: 6,036;
Total Annual Responses: 6,036; Total
Annual Hours: 81,818.
4. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Independent
Rural Health Center/Freestanding
Federally Qualified Health Center Cost
Report and Supporting Regulations in
42 CFR 413.20 and 413.24; Use: CMS is
requesting re-approval of a currently
approved form, CMS 222 (OMB No.
0938–0107). The current form
implements various provisions of the
Social Security Act including Section
1861(aa) which provides coverage under
Part B of the Medicare program for
certain services furnished by Rural
Health Clinics (RHCs) and Freestanding
Federally Qualified Health Clinics
(FQHCs), including physician assistant
and nurse practitioner services. The
Medicare regulations provide for
payment to clinics which are not part of
a hospital (freestanding clinics) under
an all-inclusive rate method designed to
pay Medicare’s share of the clinics’
incurred reasonable costs for the
services provided. Clinics which are
part of a hospital are paid in accordance
with the program’s hospital
reimbursement methods and principles.;
Form Numbers: CMS–222 (OMB #
0938–0107); Frequency: Reporting—
Annually; Affected Public: Not-for-profit
institutions, Business or other for-profit,
and State, local or tribal government;
Number of Respondents: 3000; Total
Annual Responses: 3000; Total Annual
Hours: 150,000.
To obtain copies of the supporting
statement and any related forms for the
proposed paperwork collections
referenced above, access CMS Web site
address at https://www.cms.hhs.gov/
regulations/pra/, or e-mail your request,
including your address, phone number,
OMB number, and CMS document
identifier, to Paperwork@cms.hhs.gov,
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.
PO 00000
Frm 00027
Fmt 4703
Sfmt 4703
21199
Dated: April 15, 2005.
Michelle Short,
Acting Director, CMS Office of Strategic
Operations and Regulatory Affairs,
Regulations Development Group.
[FR Doc. 05–8162 Filed 4–22–05; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifier: CMS–1856 & 1893,
CMS–R–273]
Agency Information Collection
Activities: Proposed Collection;
Comment Request
Centers for Medicare &
Medicaid Services.
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) 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: Request for
Certification in the Medicare and/or
Medicaid Program to Provide Outpatient
Physical Therapy (OPT) and/or Speech
Pathology Services, OPT Speech
Pathology Survey Report and
Supporting Regulations in 42 CFR
485.701–485.729.; Form No.: CMS–
1856, CMS–1893 (OMB # 0938–0065);
Use: The Medicare Program requires
OPT providers to meet certain health
and safety requirements. The request for
certification form is used by State
agency surveyors to determine if
minimum Medicare eligibility
requirements are met. The survey report
form records the result of the on-site
survey; Frequency: On occasion and
Other—every 6 years; Affected Public:
Business or other for-profit; Number of
AGENCY:
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]]>Agencies
[Federal Register Volume 70, Number 78 (Monday, April 25, 2005)]
[Notices]
[Pages 21198-21199]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 05-8162]
=======================================================================
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifier: CMS-287, CMS-1771, CMS-R-71, CMS-222]
Agency Information Collection Activities: Submission for OMB
Review; Comment Request
AGENCY: 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 Request: Revision of a currently approved
collection; Title of Information Collection: Home Office Cost Statement
and Supporting Regulations in 42 CFR 413.17 and 413.20; Use: The Home
Office Cost Statement is filed annually by Chain Home Offices to report
the information necessary for the determination of Medicare
reimbursement to components of chain organizations. Many providers of
service participating in Medicare are reimbursed, at least partially,
on the basis of the lesser of reasonable cost or customary services for
services furnished to eligible beneficiaries. When providers obtain
services, supplies or facilities from an organization related to the
provider by common ownership or control, 42 CFR 413.17 requires that
the provider include in its costs, the costs incurred by the related
organization in
[[Page 21199]]
furnishing such services, supplies or facilities. Revisions to this
form include the addition of columns for more detailed reporting and
the elimination of other columns that were deemed unnecessary; Form
Number: CMS-287 (OMB 0938-0202); Frequency: Annually;
Affected Public: Not-for-profit institutions and Business or other for-
profit; Number of Respondents: 1,231; Total Annual Responses: 1,231;
Total Annual Hours: 573,646.
2. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Attending
Physicians Statement and Documentation of a Medicare Emergency and
Supporting Regulations in 42 CFR 424.103; Use: 42 CFR 424.103(b)
requires that before a nonparticipating hospital may be paid for
emergency services rendered to a Medicare beneficiary, a statement must
be submitted that is sufficiently comprehensive to support that an
emergency existed. Form CMS-1771 contains a series of questions
relating to the medical necessity of the emergency. The attending
physician must attest that the hospitalization was required under the
regulatory emergency definition (42 CFR 424.101 attached) and give
clinical documentation to support the claim; Form Number: CMS-1771 (OMB
: 0938-0023); Frequency: Reporting--On occasion; Affected
Public: Business or other for-profit; Number of Respondents: 200; Total
Annual Responses: 200; Total Annual Hours: 50.
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Quality
Improvement Organization (QIO) Assumption of Responsibilities and
Supporting Regulations in 42 CFR 412.44, 412.46, 431.630, 476.71,
476.73, 476.74, and 476.78; Use: The Peer Review Improvement Act of
1982 amended Title XI of the Social Security Act to create the
Utilization and Quality Control Peer Review Organization (PRO) program
which replaces the Professional Standards Review Organization (PSRO)
program and streamlines peer review activities. The term PRO has been
renamed Quality Improvement Organization (QIO). This collection
describes the review functions to be performed by the QIO. It outlines
relationships among QIOs, providers, practitioners, beneficiaries,
intermediaries, and carriers; Form Numbers: CMS-R-71 (OMB
0938-0445); Frequency: Recordkeeping and Third Party Disclosure, as
needed; Affected Public: Business or other for-profit; Number of
Respondents: 6,036; Total Annual Responses: 6,036; Total Annual Hours:
81,818.
4. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Independent Rural
Health Center/Freestanding Federally Qualified Health Center Cost
Report and Supporting Regulations in 42 CFR 413.20 and 413.24; Use: CMS
is requesting re-approval of a currently approved form, CMS 222 (OMB
No. 0938-0107). The current form implements various provisions of the
Social Security Act including Section 1861(aa) which provides coverage
under Part B of the Medicare program for certain services furnished by
Rural Health Clinics (RHCs) and Freestanding Federally Qualified Health
Clinics (FQHCs), including physician assistant and nurse practitioner
services. The Medicare regulations provide for payment to clinics which
are not part of a hospital (freestanding clinics) under an all-
inclusive rate method designed to pay Medicare's share of the clinics'
incurred reasonable costs for the services provided. Clinics which are
part of a hospital are paid in accordance with the program's hospital
reimbursement methods and principles.; Form Numbers: CMS-222 (OMB
0938-0107); Frequency: Reporting--Annually; Affected Public:
Not-for-profit institutions, Business or other for-profit, and State,
local or tribal government; Number of Respondents: 3000; Total Annual
Responses: 3000; Total Annual Hours: 150,000.
To obtain copies of the supporting statement and any related forms
for the proposed paperwork collections referenced above, access CMS Web
site address at https://www.cms.hhs.gov/regulations/pra/, or e-mail your
request, including your address, phone number, OMB number, and CMS
document identifier, to Paperwork@cms.hhs.gov, 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.
Dated: April 15, 2005.
Michelle Short,
Acting Director, CMS Office of Strategic Operations and Regulatory
Affairs, Regulations Development Group.
[FR Doc. 05-8162 Filed 4-22-05; 8:45 am]
BILLING CODE 4120-01-P
