Agency Information Collection Activities: Proposed Collection; Comment Request

AGENCY:

Health Care Financing Administration, DHHS.

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, 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.

Type of Information Request: New collection; Title of Information Collection: Ambulance Attachment Form; Form Number: HCFA-10027 (OMB approval #: 0938-NEW); Use: This form is used by ambulance suppliers in Missouri to report information needed to process their claims; it is an attachment to the HCFA form 1491, which is used to submit ambulance claims; Frequency: On occasion; Affected Public: Business or other for-profit, Not-for-profit institutions, State, local, or tribal gov; Number of Respondents: Total Annual Responses: 5,000; Total Annual Hours Requested: 167 hours.

To obtain copies of the supporting statement and any related forms 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, phone number, OMB number, and HCFA document identifier, 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 60 days of this notice directly to the HCFA Paperwork Clearance Officer designated at the following address: HCFA, Office of Information Services, Security and Standards Group, Division of HCFA Enterprise Standards, Attention: Julie Brown, HCFA-10027; Room N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.