Information Collection

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

IC 46422 under ICR 201001-0938-009 · OMB 0938-0676.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-304a Prior Quarter Adjustment Statement Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304A)	Form
CMS-304a Instructions revised.doc	Instruction
Appendix A for CMS-304a.doc	Other-Other
PQAS APPENDIX C.doc	Other-Other
PQAS Form With Disclosure Statement.XLS	Other- PQAS Form With Disclosure Sta
CMS-304a Prior Quarter Adjustment Statement Prior Quarter Adjustment Statement Form.XLS	Form

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: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of 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
Other-Other			Appendix A for CMS-304a.doc	No	No	Paper Only
Other-Other			PQAS APPENDIX C.doc	No	No	Paper Only
Other- PQAS Form With Disclosure Statement			PQAS Form With Disclosure Statement.XLS	No		Paper Only
Instruction			CMS-304a Instructions revised.doc	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 570

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,280	80	2,200
Annual IC Time Burden (Hours)	45,600	1,600	44,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.