[Federal Register: September 17, 1999 (Volume 64, Number 180)]
[Notices]               
[Page 50521]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr17se99-78]                         

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[Document Identifier: HCFA-1964]

 
Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Health Care Financing Administration.
    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 Collection Request: Extension of a currently 
approved collection;
    Title of Information Collection: Request for Review of Part B 
Medicare Claim and Supporting Regulations in 42 CFR 405.807;
    Form No.: HCFA-1964 (OMB# 0938-0033);
    Use: The HCFA-1964 is a form which is used nationally to request 
review of an initial determination made on a Part B health insurance 
claim. A Medicare beneficiary (or his/her physician/supplier who 
accepts assignment) files for Part B benefits using forms HCFA-1490S 
(Patient's Request for Medicare Payment), HCFA-1491 (Request for 
Medicare Payment--Ambulance), or HCFA-1500 (Health Insurance Claim 
Form). If any benefits are denied, the claimant has the right to 
request a review of the initial determination by submitting this HCFA-
1964, form.;
    Frequency: On occasion;
    Affected Public: Individuals or Households, and Not-for-profit 
institutions;
    Number of Respondents: 5,600,000;
    Total Annual Responses: 5,600,000;
    Total Annual Hours: 1,400,000.
    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: Dawn Willinghan, Room N2-14-26, 7500 
Security Boulevard, Baltimore, Maryland 21244-1850.

    Dated: September 9, 1999.
John P. Burke III,
HCFA Reports Clearance Officer, HCFA Office of Information 
Services,Security and Standards Group, Division of HCFA Enterprise 
Standards.
[FR Doc. 99-24269 Filed 9-16-99; 8:45 am]
BILLING CODE 4120-03-P