Agency Information Collection Activities: Submission for OMB Review; Comment Request, 19267-19269 [2021-07478]
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19267
Federal Register / Vol. 86, No. 69 / Tuesday, April 13, 2021 / Notices
SUMMARY OF ANNUAL BURDEN
Type of burden
Obligation
to respond
Reporting .................
Mandatory ................
Information collection description
Interagency Notice of Change in Director
or Executive Officer.
Total Estimated Annual Burden: 214
hours.
General Description of Collection:
Section 32 of the FDIA (12 U.S.C. 1831i)
requires an insured depository
institution or depository institution
holding company under certain
circumstances to notify the appropriate
federal banking agency of the proposed
addition of any individual to the board
of directors or the employment of any
individual as a senior executive officer
of such institution at least 30 days
before such addition or employment
becomes effective. Section 32 of the
FDIA also provides that the FDIC may
disapprove an individual’s service as a
director or senior executive officer of
certain state nonmember banks or state
savings associations if, upon assessing
the individual’s competence,
experience, character, and integrity, it is
determined that the individual’s service
would not be in the best interest of the
depositors of the institution or the
public. The Interagency Notice of
Change in Director or Senior Executive
Officer, with the information contained
in the Interagency Biographical and
Financial Report (described above) as an
attachment, is used by the FDIC to
collect information relevant to assess
the individual’s competence,
experience, character, and integrity.
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Request for Comment
Comments are invited on: (a) Whether
the collection of information is
necessary for the proper performance of
the FDIC’s functions, including whether
the information has practical utility; (b)
the accuracy of the estimates of the
burden of the information collection,
including the validity of the
methodology and assumptions used; (c)
ways to enhance the quality, utility, and
clarity of the information to be
collected; and (d) ways to minimize the
burden of the collection of information
on respondents, including through the
use of automated collection techniques
or other forms of information
technology. All comments will become
a matter of public record.
Federal Deposit Insurance Corporation.
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Estimated
number of
respondents
I
107
Estimated
time per
response
(hours)
Estimated
frequency of
responses
On Occasion ............
I
Dated at Washington, DC, on April 7, 2021.
James P. Sheesley,
Assistant Executive Secretary.
[FR Doc. 2021–07498 Filed 4–12–21; 8:45 am]
BILLING CODE 6714–01–P
I
2
Estimated
annual
burden
(hours)
I
214
Prevention and the Agency for Toxic
Substances and Disease Registry.
Kalwant Smagh,
Director, Strategic Business Initiatives Unit,
Office of the Chief Operating Officer, Centers
for Disease Control and Prevention.
[FR Doc. 2021–07487 Filed 4–12–21; 8:45 am]
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
BILLING CODE 4163–18–P
Centers for Disease Control and
Prevention
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Notice of Closed Meeting
Centers for Medicare & Medicaid
Services
Pursuant to section 10(d) of the
Federal Advisory Committee Act, as
amended, notice is hereby given of the
following meeting.
The meeting will be closed to the
public in accordance with the
provisions set forth in sections
552b(c)(4) and 552b(c)(6), Title 5 U.S.C.,
as amended, and the Determination of
the Director, Strategic Business
Initiatives Unit, Office of the Chief
Operating Officer, CDC, pursuant to
Public Law 92–463. The grant
applications and the discussions could
disclose confidential trade secrets or
commercial property such as patentable
material, and personal information
concerning individuals associated with
the grant applications, the disclosure of
which would constitute a clearly
unwarranted invasion of personal
privacy.
Name of Committee: Disease, Disability,
and Injury Prevention and Control Special
Emphasis Panel (SEP)—PAR 18–812, NIOSH
Member Conflict Review.
Date: June 24, 2021.
Time: 1:00 p.m.–4:00 p.m., EDT.
Place: Teleconference.
Agenda: To review and evaluate grant
applications.
For Further Information Contact: Michael
Goldcamp, Ph.D., Scientific Review Officer,
Office of Extramural Programs, National
Institute for Occupational Safety and Health,
CDC, 1095 Willowdale Road, Morgantown,
West Virginia 26506, Telephone (304) 285–
5951; MGoldcamp@cdc.gov.
The Director, Strategic Business Initiatives
Unit, Office of the Chief Operating Officer,
Centers for Disease Control and Prevention,
has been delegated the authority to sign
Federal Register notices pertaining to
announcements of meetings and other
committee management activities, for both
the Centers for Disease Control and
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[Document Identifier: CMS–718–721, CMS–
724, CMS–2088–17 and CMS–1763]
Agency Information Collection
Activities: Submission for OMB
Review; Comment Request
Centers for Medicare &
Medicaid Services, Health and Human
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
(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
a second opportunity for public
comment on the notice. Interested
persons are invited to send comments
regarding the burden estimate 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.
SUMMARY:
Comments on the collection(s) of
information must be received by the
OMB desk officer by May 13, 2021.
DATES:
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Federal Register / Vol. 86, No. 69 / Tuesday, April 13, 2021 / Notices
Written comments and
recommendations for the proposed
information collection should be sent
within 30 days of publication of this
notice to www.reginfo.gov/public/do/
PRAMain. Find this particular
information collection by selecting
‘‘Currently under 30-day Review—Open
for Public Comments’’ or by using the
search function.
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’ website address at
website address at: https://
www.cms.gov/Regulations-andGuidance/Legislation/
PaperworkReductionActof1995/PRAListing.html.
FOR FURTHER INFORMATION CONTACT:
William Parham at (410) 786–4669.
SUPPLEMENTARY INFORMATION: Under the
Paperwork Reduction Act of 1995 (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 (44 U.S.C.
3506(c)(2)(A)) requires federal agencies
to publish a 30-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 that summarizes
the following proposed collection(s) of
information for public comment:
1. Type of Information Collection
Request: Revision of a currently
approved collection; Title of
Information Collection: Business
Proposal Forms for Quality
Improvement Organizations (QIOs); Use:
The submission of proposal information
by current quality improvement
associations (QIOs) and other bidders,
on the appropriate forms, will satisfy
our need for meaningful, consistent, and
verifiable data with which to evaluate
contract proposals. We use the data
collected on the forms associated with
this information collection request to
negotiate QIO contracts. We will be able
to compare the costs reported by the
QIOs on the cost reports to the proposed
costs noted on the business proposal
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ADDRESSES:
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17:42 Apr 12, 2021
Jkt 253001
forms. Subsequent contract and
modification negotiations will be based
on historic cost data. The business
proposal forms will be one element of
the historical cost data from which we
can analyze future proposed costs. In
addition, the business proposal format
will standardize the cost proposing and
pricing process among all QIOs. With
well-defined cost centers and line items,
proposals can be compared among QIOs
for reasonableness and appropriateness.
Form Number: CMS–718–721 (OMB
control number: 0938–0579); Frequency:
Annually; Affected Public: Business or
other for-profits and Not-for-profit
institutions; Number of Respondents:
58; Total Annual Responses: 58; Total
Annual Hours: 2,320. (For policy
questions regarding this collection
contact Benjamin Bernstein at 410–786–
6570.)
2. Type of Information Collection
Request: Reinstatement without change
of a previously approved collection;
Title of Information Collection:
Medicare/Medicaid Psychiatric Hospital
Survey Data and Supporting
Regulations; Use: The CMS–724 form is
used to collect data that assists us in
program planning and evaluation and in
maintaining an accurate database on
providers participating in the
psychiatric hospital program.
Specifically, we use the information
collected on this form in evaluating the
Medicare psychiatric hospital program.
The form is also used for audit
purposes; determining patient
population and characteristics of the
hospital; and survey term composition.
Form Number: CMS–724 (OMB control
number: 0938–0378); Frequency:
Annually; Affected Public: Business or
other for-profits and Not-for-profit
institutions; Number of Respondents:
19; Total Annual Responses: 191; Total
Annual Hours: 96. (For policy questions
regarding this collection contact
Caroline Gallaher at 410–786–8705.)
3. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Community
Mental Health Center Cost Report Use:
CMS requires the Form CMS–2088–17
to determine a provider’s reasonable
cost incurred in furnishing medical
services to Medicare beneficiaries and
reimbursement due to or from a
provider. In addition, CMHCs may
receive reimbursement through the cost
report for Medicare reimbursable bad
debts. CMS uses the Form CMS–2088–
17 for rate setting; payment refinement
activities, including market basket
analysis; Medicare Trust Fund
projections; and to support program
operations. The primary function of the
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cost report is to determine provider
reimbursement for services rendered to
Medicare beneficiaries. Each CMHC
submits the cost report to its contractor
for reimbursement determination.
Section 1874A of the Act describes
the functions of the contractor. CMHCs
must follow the principles of cost
reimbursement, which require they
maintain sufficient financial records
and statistical data for proper
determination of costs. The S series of
worksheets collects the provider’s
location, CBSA, date of certification,
operations, and unduplicated census
days. The A series of worksheets
collects the provider’s trial balance of
expenses for overhead costs, direct
patient care services, and non-revenue
generating cost centers. The B series of
worksheets allocates the overhead costs
to the direct patient care and nonrevenue generating cost centers using
functional statistical bases. The
Worksheet C computes the
apportionment of costs between
Medicare beneficiaries and other
patients. The D series of worksheets are
Medicare specific and calculate the
reimbursement settlement for services
rendered to Medicare beneficiaries. The
Worksheet F collects the provider’s
revenues and expenses data from the
provider’s income statement. Form
Number: CMS–2088–17 (OMB control
number: 0938–0378); Frequency:
Annually; Affected Public: Private
Sector, Business or other for-profits,
Not-for-profits institutions; Number of
Respondents: 184; Total Annual
Responses: 184; Total Annual Hours:
16,560. (For policy questions regarding
this collection contact Jill Keplinger at
410–786–4550.)
4. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Request for
Termination of Premium-Hospital and
or Supplementary Medical Insurance;
Use: Form CMS–1763 provides the
necessary information to process the
enrollee’s request for termination of Part
B and/or premium Part A coverage.
Sections 1818(c)(5), 1818A(c)(2)(B)
and 1838(b)(1) of the Act and
corresponding regulations at 42 CFR
406.28(a) and 407.27(c) require that a
Medicare enrollee wishing to
voluntarily terminate Part B and/or
premium Part A coverage file a written
request with CMS or SSA. The statute
and regulations also specify when
coverage ends based upon the date the
request for termination is filed.
Form CMS–1763 collects the
information necessary to process
Medicare enrollment terminations. The
Request for Termination of Premium
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Federal Register / Vol. 86, No. 69 / Tuesday, April 13, 2021 / Notices
Hospital and/or Supplementary Medical
Insurance (Form CMS–1763) provides a
standardized means to satisfy the
requirements of law, as well as allow
both agencies to protect the individual
from an inappropriate decision. Form
Number: CMS–1763 (OMB control
number: 0938–0025); Frequency:
Annually; Affected Public: State, Local,
or Tribal Governments; Number of
Respondents: 114,215; Total Annual
Responses: 114,215; Total Annual
Hours: 19,074. (For policy questions
regarding this collection contact Carla
Patterson at 410–786–1000.)
Dated: April 7, 2021.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2021–07478 Filed 4–12–21; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifier: CMS–10757]
Agency Information Collection
Activities: Proposed Collection;
Comment Request
Centers for Medicare &
Medicaid Services, Health and Human
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
June 14, 2021.
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SUMMARY:
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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: CMS–P–0015A, 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’ website address at
https://www.cms.gov/Regulations-andGuidance/Legislation/
PaperworkReductionActof1995/PRAListing.html.
FOR FURTHER INFORMATION CONTACT:
William N. Parham at (410) 786–4669.
SUPPLEMENTARY INFORMATION:
ADDRESSES:
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–10757 CLIA Collection of
Information Requirements Related to
SARS–CoV–2 Test Results Reporting
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
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19269
requirement, CMS is publishing this
notice.
Information Collection
1. Type of Information Collection
Request: Extension of a currently
approved information collection; Title
of Information Collection: CLIA
Collection of Information Requirements
Related to SARS–CoV–2 Test Results
Reporting; Use: In order to be in
compliance with the new CLIA
mandatory SARS–CoV–2 test results
reporting requirements, laboratories will
need to develop a mechanism to track,
collect, and report test results as well as
update policies and procedures. In
addition, Accreditation Organizations
(AOs) and Exempt States (ESs) will need
to update laboratory standards to reflect
the reporting requirements and update
policies and procedures related to
reporting laboratories that do not report
test results as required.
The CDC has an information
collection request (OMB Control
Number 0920–1299) in order to collect
laboratory data related to the COVID–19
Pandemic Response. The CMS package
(ICR) is for laboratory implementation
and CMS monitoring of compliance
with the CMS–3401–IFC CLIA-certified
laboratory reporting requirements.
The information collected by the
Centers for Medicare and Medicaid
Services (CMS) or its designee, such as
a CMS agent or CMS approved
laboratory accreditation organization,
when conducting inspections will be
used to determine a laboratory’s
compliance with the CLIA SARS–CoV–
2 test result reporting requirements.
During an on-site survey, the Conditionlevel laboratory requirement at 42 CFR
493.41and 493.1100(a) are assessed for
compliance. The information is used by
CMS in determining appropriate Civil
Money Penalties (CMPs) when
laboratories fail to report as required.
Form Number: CMS–10757 (OMB
control number: 0938–1391); Frequency:
Daily; Affected Public: Private Sector
Not-for-profit institutions and State,
Local and Tribal Governments; Number
of Respondents: 77,033; Total Annual
Responses: 308,114; Total Annual
Hours: 1,386,873 (For policy questions
regarding this collection contact Sarah
Bennett at 410–786–3354.)
Dated: April 8, 2021.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2021–07559 Filed 4–12–21; 8:45 am]
BILLING CODE 4120–01–P
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]]>Agencies
[Federal Register Volume 86, Number 69 (Tuesday, April 13, 2021)]
[Notices]
[Pages 19267-19269]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-07478]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifier: CMS-718-721, CMS-724, CMS-2088-17 and CMS-1763]
Agency Information Collection Activities: Submission for OMB
Review; Comment Request
AGENCY: Centers for Medicare & Medicaid Services, Health and Human
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 (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 a second opportunity
for public comment on the notice. Interested persons are invited to
send comments regarding the burden estimate 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 on the collection(s) of information must be received by
the OMB desk officer by May 13, 2021.
[[Page 19268]]
ADDRESSES: Written comments and recommendations for the proposed
information collection should be sent within 30 days of publication of
this notice to www.reginfo.gov/public/do/PRAMain. Find this particular
information collection by selecting ``Currently under 30-day Review--
Open for Public Comments'' or by using the search function.
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' website address at website address at: https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.
FOR FURTHER INFORMATION CONTACT: William Parham at (410) 786-4669.
SUPPLEMENTARY INFORMATION: Under the Paperwork Reduction Act of 1995
(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 (44 U.S.C. 3506(c)(2)(A)) requires
federal agencies to publish a 30-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 that
summarizes the following proposed collection(s) of information for
public comment:
1. Type of Information Collection Request: Revision of a currently
approved collection; Title of Information Collection: Business Proposal
Forms for Quality Improvement Organizations (QIOs); Use: The submission
of proposal information by current quality improvement associations
(QIOs) and other bidders, on the appropriate forms, will satisfy our
need for meaningful, consistent, and verifiable data with which to
evaluate contract proposals. We use the data collected on the forms
associated with this information collection request to negotiate QIO
contracts. We will be able to compare the costs reported by the QIOs on
the cost reports to the proposed costs noted on the business proposal
forms. Subsequent contract and modification negotiations will be based
on historic cost data. The business proposal forms will be one element
of the historical cost data from which we can analyze future proposed
costs. In addition, the business proposal format will standardize the
cost proposing and pricing process among all QIOs. With well-defined
cost centers and line items, proposals can be compared among QIOs for
reasonableness and appropriateness. Form Number: CMS-718-721 (OMB
control number: 0938-0579); Frequency: Annually; Affected Public:
Business or other for-profits and Not-for-profit institutions; Number
of Respondents: 58; Total Annual Responses: 58; Total Annual Hours:
2,320. (For policy questions regarding this collection contact Benjamin
Bernstein at 410-786-6570.)
2. Type of Information Collection Request: Reinstatement without
change of a previously approved collection; Title of Information
Collection: Medicare/Medicaid Psychiatric Hospital Survey Data and
Supporting Regulations; Use: The CMS-724 form is used to collect data
that assists us in program planning and evaluation and in maintaining
an accurate database on providers participating in the psychiatric
hospital program. Specifically, we use the information collected on
this form in evaluating the Medicare psychiatric hospital program. The
form is also used for audit purposes; determining patient population
and characteristics of the hospital; and survey term composition. Form
Number: CMS-724 (OMB control number: 0938-0378); Frequency: Annually;
Affected Public: Business or other for-profits and Not-for-profit
institutions; Number of Respondents: 19; Total Annual Responses: 191;
Total Annual Hours: 96. (For policy questions regarding this collection
contact Caroline Gallaher at 410-786-8705.)
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Community Mental
Health Center Cost Report Use: CMS requires the Form CMS-2088-17 to
determine a provider's reasonable cost incurred in furnishing medical
services to Medicare beneficiaries and reimbursement due to or from a
provider. In addition, CMHCs may receive reimbursement through the cost
report for Medicare reimbursable bad debts. CMS uses the Form CMS-2088-
17 for rate setting; payment refinement activities, including market
basket analysis; Medicare Trust Fund projections; and to support
program operations. The primary function of the cost report is to
determine provider reimbursement for services rendered to Medicare
beneficiaries. Each CMHC submits the cost report to its contractor for
reimbursement determination.
Section 1874A of the Act describes the functions of the contractor.
CMHCs must follow the principles of cost reimbursement, which require
they maintain sufficient financial records and statistical data for
proper determination of costs. The S series of worksheets collects the
provider's location, CBSA, date of certification, operations, and
unduplicated census days. The A series of worksheets collects the
provider's trial balance of expenses for overhead costs, direct patient
care services, and non-revenue generating cost centers. The B series of
worksheets allocates the overhead costs to the direct patient care and
non-revenue generating cost centers using functional statistical bases.
The Worksheet C computes the apportionment of costs between Medicare
beneficiaries and other patients. The D series of worksheets are
Medicare specific and calculate the reimbursement settlement for
services rendered to Medicare beneficiaries. The Worksheet F collects
the provider's revenues and expenses data from the provider's income
statement. Form Number: CMS-2088-17 (OMB control number: 0938-0378);
Frequency: Annually; Affected Public: Private Sector, Business or other
for-profits, Not-for-profits institutions; Number of Respondents: 184;
Total Annual Responses: 184; Total Annual Hours: 16,560. (For policy
questions regarding this collection contact Jill Keplinger at 410-786-
4550.)
4. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Request for
Termination of Premium-Hospital and or Supplementary Medical Insurance;
Use: Form CMS-1763 provides the necessary information to process the
enrollee's request for termination of Part B and/or premium Part A
coverage.
Sections 1818(c)(5), 1818A(c)(2)(B) and 1838(b)(1) of the Act and
corresponding regulations at 42 CFR 406.28(a) and 407.27(c) require
that a Medicare enrollee wishing to voluntarily terminate Part B and/or
premium Part A coverage file a written request with CMS or SSA. The
statute and regulations also specify when coverage ends based upon the
date the request for termination is filed.
Form CMS-1763 collects the information necessary to process
Medicare enrollment terminations. The Request for Termination of
Premium
[[Page 19269]]
Hospital and/or Supplementary Medical Insurance (Form CMS-1763)
provides a standardized means to satisfy the requirements of law, as
well as allow both agencies to protect the individual from an
inappropriate decision. Form Number: CMS-1763 (OMB control number:
0938-0025); Frequency: Annually; Affected Public: State, Local, or
Tribal Governments; Number of Respondents: 114,215; Total Annual
Responses: 114,215; Total Annual Hours: 19,074. (For policy questions
regarding this collection contact Carla Patterson at 410-786-1000.)
Dated: April 7, 2021.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and
Regulatory Affairs.
[FR Doc. 2021-07478 Filed 4-12-21; 8:45 am]
BILLING CODE 4120-01-P
