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

IC 8261 under ICR 201001-0938-009 · OMB 0938-0676.

Documents and Forms
Document Name
Document Type
Other-Other
Instruction
Other-Other
Form
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Reconciliation of State Invoice and Prior Quarter Adjustment Statement (CMS-304)
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
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 for ROSI 2009 with disclosure statement.doc No   Paper Only
Form CMS-304 Reconciliation of State Invoice ROSI Form with Disclosure Statement with disclosure statement.XLS No   Paper Only

Health Health Care Services

 

385 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,540 0 0 0 0 1,540
Annual IC Time Burden (Hours) 95,480 0 0 0 0 95,480
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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