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

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⚠️ Notice: This information collection may be referencing outdated material.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-304 Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304) Form
Appendix A.doc Other-Other
CMS-304 Instructions.doc Instruction
Appendix C Adjustment--Dispute Codes.doc Other-Other
CMS-304 Reconciliation of State Invoice CMS-304 Form.XLS Form

Information Collection (IC) Details

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

Is this a Common Form? No		IC Status: Modified

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-304	Reconciliation of State Invoice	CMS-304 Form.XLS	No	No	Paper Only
Other-Other			Appendix A.doc	No	No	Paper Only
Other-Other			Appendix C Adjustment--Dispute Codes.doc	No	No	Paper Only
Instruction			CMS-304 Instructions.doc	No	No	Paper Only

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 385	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	Previously Approved
Annual Number of Responses for this IC	1,540	-2,204	3,744
Annual IC Time Burden (Hours)	95,480	-44,080	139,560
Annual IC Cost Burden (Dollars)	0	-350,000	350,000

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.