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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 8261 under ICR 201107-0938-007 · OMB 0938-0676.

Documents and Forms
Document Name
Document Type
Form
Other-Appendix
Instruction
Other-Appendix
Form
IC Document
IC Document
Information Collection (IC) Details

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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
Form CMS-304 Reconciliation of State Invoice (ROSI) ROSI Form wiith Disclosure Statement_2011.pdf Yes Yes Fillable Printable
Other-Appendix Appendix A for CMS-304_Final_ 2011.doc Yes No Fillable Printable
Instruction Instructions for CMS-304 ROSI_Final_2011.doc Yes No Printable Only
Other-Appendix Appendix C for CMS-304 & 304a_2011.doc Yes No Printable Only

Health Health Care Services

 

416 41
   
Private Sector Businesses or other for-profits
 
   85 %

  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 1,664 124 0 0 0 1,540
Annual IC Time Burden (Hours) 116,480 21,000 0 0 0 95,480
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crossswalk - Instructions (CMS-304) CMS-304 Instructions - Crosswalk [rev 07-19-11].doc 07/19/2011
Crosswalk - Appendix A (CMS-304) CMS-304 Appendix A - Croswalk [rev 07-19-11].doc 07/19/2011
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.