Agency Forms Undergoing Paperwork Reduction Act Review

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

Agency Forms Undergoing Paperwork Reduction Act Review

Periodically, the Health Resources and Services Administration

(HRSA) publishes abstracts of information collection requests under

review by the Office of Management and Budget, in compliance with the

Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35). To request a

copy of the clearance requests submitted to OMB for review, call the

HRSA Reports Clearance Office on (301)-443-1129.

The following request has been submitted to the Office of

Management and Budget for review under the Paperwork Reduction Act of

1995:

Health Education Assistance Loan (HEAL) Program Physician's

Certification of Borrower's Total and Permanent Disability Form--New--

This form, completed by the HEAL borrower, the borrower's physician,

and the holder of the loan, is used to certify that the HEAL borrower

meets the total and permanent disability provisions. The PHS will use

this form to obtain precise information about the disability claim

which includes the following: (1) The borrower's consent to release

medical records to the Department of Health and Human Services and to

the holder of the borrower's HEAL loans, (2) pertinent information

supplied by the certifying physician, (3) the physician's certification

that the borrower is unable to engage in any substantial gainful

activity because of a medically determinable impairment that is

expected to continue for a long and indefinite period of time or to

result in death, and (4) information from the lender on the unpaid

balance. Failure to submit the required documentation will result in a

disability claim not being honored.

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Responses Average Total

Type of respondent Number of per burden per burden

respondents respondent response (hours)

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Borrower.................................................... 42 1.0 0.08 3

Physician................................................... 42 1.0 2.75 116

Lender...................................................... 35 1.2 0.17 7

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Estimated Total Annual Burden: 126 hours.

Written comments and recommendations concerning the proposed

information collection should be sent within 30 days of this notice to:

Allison Eydt, Human Resources and Housing Branch, Office of Management

and Budget, New Executive Office Building, Room 10235, Washington, D.C.

20503.

Dated: December 1, 1995.

J. Henry Montes,

Associate Administrator for Policy Coordination

[FR Doc. 95-29810 Filed 12-6-95; 8:45 am]

BILLING CODE 4160-15-P