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

In compliance with the requirement of section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995, the Health Care Financing Administration (HCFA), Department of Health and Human Services, has submitted to the Office of Management and Budget (OMB) the following proposal for the collection of information. Interested persons are invited to send comments regarding the 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: Revision of a currently approved collection;

Title of Information Collection: Qualification Application and Supporting Regulations in 42 CFR Section 417.408 and 417.143;

Form No.: HCFA-901-1 (OMB# 0938-0470);

Use: Prepaid health plans must meet certain regulatory requirements to be federally qualified health maintenance organizations. This application is the collection form used to obtain the information from health plans that allow HCFA staff to determine compliance with the regulations;

Frequency: Other: One-time;

Affected Public: Business or other for-profit, not-for-profit institutions, and State, Local, or Tribal Government;

Number of Respondents: 35;

Total Annual Responses: 35;

Total Annual Hours: 3,500.

(2) 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 and Supporting Regulations in 42 CFR 406.28 and 407.27;

Form No.: HCFA-1763 (OMB No. 0938-0025);

Use: The HCFA-1763 is used by beneficiaries to request voluntary termination from premium hospital and/or supplementary medical insurance;

Frequency: One time only;

Affected Public: Individuals or Households, Federal Government, and State, Local or Tribal Government;

Number of Respondents: 14,000;

Total Annual Responses: 14,000;

Total Annual Hours: 5,833.

To obtain copies of the supporting statement for the proposed paperwork collections referenced above, access HCFA's Web site address at http://www.hcfa.gov/regs/prdact95.htm,, or E-mail your request, including your address and phone number, to Paperwork@hcfa.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 designated at the following address: OMB Human Resources and Housing Branch, Attention: Allison Eydt, New Executive Office Building, Room 10235, Washington, DC 20503.