Information Collection

Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)

IC 213568 under ICR 201605-0938-019 · OMB 0938-1265.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1265 can be found here:

Documents and Forms

Document Name Document Type
Crosswalk - CMS-64.pdf Crosswalk IC Document
Form Descriptions.docx Form Descriptions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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

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)	8,960	8,960
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk - CMS-64.pdf	10/22/2014
Form Descriptions	Form Descriptions.docx	10/22/2014

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