Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304A)

Reconciliation of State Invoice and Prior Quarter Adjustment Statement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0676 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-304a Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304A) Form
CMS-304a Instructions.doc Instruction
Appendix A for CMS-304a.doc Other-Other
PQAS APPENDIX C.doc Other-Other
CMS-304a Prior Quarter Adjustment Statement Prior Quarter Adjustment Statement Form.XLS Form

Information Collection (IC) Details

IC Title:	Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304A)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-304a	Prior Quarter Adjustment Statement	Prior Quarter Adjustment Statement Form.XLS	No	No	Paper Only
Instruction			CMS-304a Instructions.doc	No	No	Paper Only
Other-Other			Appendix A for CMS-304a.doc	No	No	Paper Only
Other-Other			PQAS APPENDIX C.doc	No	No	Paper Only

Line of Business: Health

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 550	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,200	2,200
Annual IC Time Burden (Hours)	44,000	44,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.