Information Collection

Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program

IC 7827 under ICR 201103-0938-010 · OMB 0938-0067.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0067 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-64 Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program Form
CMS-64 Quarterly Medicaid Statement of Expenditures CMS-64 Forms.pdf Form
CMS-64 Disclosure Statement.doc CMS-64 Disclosure Statement IC Document
CMS-64 - Crosswalk.xlsx CMS-64 Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-64	Quarterly Medicaid Statement of Expenditures	CMS-64 Forms.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	224	224
Annual IC Time Burden (Hours)	18,144	18,144
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-64 Disclosure Statement	CMS-64 Disclosure Statement.doc	06/06/2008
CMS-64 Crosswalk	CMS-64 - Crosswalk.xlsx	02/26/2011

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