Information Collection

Medicaid Report on Payables and Receivables

IC 43663 under ICR 201305-0938-003 · OMB 0938-0697.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0697 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-R-199.MedicaidInstructions508.pdf	Instruction
CMS-R-199 CMS-R-199 CMS-R-199 Revised Form(2011).doc	Form

IC Title:

Medicaid Report on Payables and Receivables

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
Instruction			CMS-R-199.MedicaidInstructions508.pdf		Yes	Yes	Fillable Fileable
Form	CMS-R-199	CMS-R-199	CMS-R-199 Revised Form(2011).doc		Yes	No	Fillable Printable

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: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	392	56	336
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.