OMB.report

Federal forms, ICRs, and supporting documents

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⚠️ Notice: This information collection may be referencing outdated material.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:

2013-05-28 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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	224	0	0	0	0	224
Annual IC Time Burden (Hours)	18,144	0	0	0	0	18,144
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
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.