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

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

⚠️ Notice: This information collection may be referencing outdated material.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
Appendix A.doc Other-Other
CMS-304 Instructions for ROSI 2009 with disclosure statement.doc Instruction
Appendix C Adjustment--Dispute Codes.doc Other-Other
CMS-304 Reconciliation of State Invoice ROSI Form with Disclosure Statement with disclosure statement.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
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

Line of Business: Health

Subfunction: Health Care Services

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	Previously Approved
Annual Number of Responses for this IC	1,540	1,540
Annual IC Time Burden (Hours)	95,480	95,480
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.