Information Collection

Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program

IC 7827 under ICR 201305-0938-020 · OMB 0938-0067.

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 Assistance Expenditures For the Medic CMS 64 Forms.pdf Form
Copy of CMS-64_-_Crosswalk.xlsx Crosswalk IC Document
CMS-64 Disclosure Statement.doc Disclosure Statement IC Document
64 9 form.docx 64 9 form IC Document
64 10 screen.docx 64 10 screen 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 Assistance Expenditures For the Medical Assistance Program	CMS 64 Forms.pdf		Yes	Yes	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: 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
Crosswalk	Copy of CMS-64_-_Crosswalk.xlsx	05/24/2013
Disclosure Statement	CMS-64 Disclosure Statement.doc	05/24/2013
64 9 form	64 9 form.docx	06/13/2013
64 10 screen	64 10 screen.docx	06/13/2013

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