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

New collection - Hospital Leadership Quality Assessment Tool (HLQAT) In 2006, the Hospital Leadership Collaborative (HLC) launched a public-private partnership to develop a CMS-endorsed self-assessment tool, ``The Hospital Leadership and Quality Assessment Tool'' (HLQAT) to assist hospitals in the improvement of quality through enhanced hospital governance, executive, physician, and clinical engagement. Hospitals leaders will take the HLQAT instrument via Web-based technology. This function will be carried out in conjunction with CMS and the Quality Improvement Organization (QIO) 9th Scope of Work (SOW), to convey the importance of this effort in relation to Medicare and other public priorities. This administration of the HLQAT seeks responses from approximately a dozen leaders in each hospital, including physicians (e.g., CEO, CMO), board members, director-level, and mid-level clinical managers--these responses can provide a multi-level representation of hospital leadership showing its commitment to institutional change. Revision of a currently approved collection - National Medicare & You Education Program (NMEP) Survey of Medicare Beneficiaries

The Centers for Medicare and Medicaid Services is requesting a revision of this information collection request to continue to collect information from Medicare beneficiaries, caregivers, health care providers, and health information providers. It is critical for this agency to obtain feedback from the aforementioned groups so that the agency can accurately assess the needs of the Medicare audience. Using random digit dial and/or an administrative sample, members of the Medicare audience will be called and asked to complete the survey via telephone. The results of this survey will be compiled and studied so that communication may be amended to benefit Medicare's audience. The survey has the following objectives:

• To assess satisfaction with and knowledge of the Medicare program;
• to gather information on health behaviors and quality of health care;
• to determine the most used source for Medicare information; and to
• gather information from health care provider and health information providers.

Revision of a currently approved collection - Request for Certification as Rural Health Clinic (RHC) and RHC Survey Report The CMS-29 is utilized as an application to be completed by suppliers of RHC services requesting participation in the Medicare/Medicaid programs. This form initiates the process of obtaining a decision as to whether the conditions for certification are met as a supplier of RHC services.

Revision of a currently approved collection - Annual Report on Home and Community Based Services Waivers States within an approved waiver under section 1915(c) of the act are required to submit a report annually in order for CMS to: (1) Verify that State assurances regarding waiver cost-neutrality are met; and, (2) Determine the waiver's impact on the type, amount, and cost of services provided under the State Plan and health welfare of recipients.

New collection - Emergency and Non-Emergency Ambulance Transports and Beneficiary Signature Requirements In the CY 2008 Physician Fee Schedule (PFS) final rule with comment period, we created an additional exception to the beneficiary signature requirements in Sec. 424.36(b) for emergency ambulance transports (72 FR 66406). The exception allows ambulance providers and suppliers to sign the claim on behalf of the beneficiary, at the time of transport, provided that certain documentation requirements are met. Following publication of the CY 2008 PFS final rule with comment period, ambulance provider and supplier stakeholders requested that we extend the exception in Sec. 424.36(b)(6) to non-emergency ambulance transports, in instances where the beneficiary is physically or mentally incapable of signing the claim form. The current submission of this information collection request relates to the collection of documentation pertaining to non-emergency ambulance transports. In addition, we are updating the collection of information that relates to the collection of documentation pertaining to emergency ambulance transports.