Prior Quarter Adjustment Statement (PQAS, CMS-304A)

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0676 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-304a Prior Quarter Adjustment Statement (PQAS, CMS-304A) Form
Appendix A for CMS-304a_2014.pdf Instruction
Appendix C for CMS-304 304a_2014.pdf Instruction
INSTRUCT.PDF Instruction
CMS-304a Prior Quarter Adjustment Statement (PQAS) PQAS Form with Disclosure Statement_2014.pdf Form

Information Collection (IC) Details

IC Title:	Prior Quarter Adjustment Statement (PQAS, CMS-304A)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-304a	Prior Quarter Adjustment Statement (PQAS)	PQAS Form with Disclosure Statement_2014.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix A for CMS-304a_2014.pdf	Yes	Yes	Fillable Printable
Instruction			Appendix C for CMS-304 304a_2014.pdf	Yes	No	Printable Only
Instruction			INSTRUCT.PDF	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 610	Number of Respondents for Small Entity: 60

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 85 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,440	60	2,380
Annual IC Time Burden (Hours)	68,320	1,680	66,640
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.