Information Collection

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

IC 46422 under ICR 201704-0938-010 · OMB 0938-0676.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-304a Prior Quarter Adjustment Statement (PQAS) Prior Quarter Adjustment Statement (PQAS) (CMS-304A)	Form
Appendix A for CMS-304a_2017.pdf	Instruction
Appendix C for CMS-304_304a_2017 .pdf	Instruction
Instructions for CMS-304a PQAS_2017.pdf	Instruction
CMS-304a Prior Quarter Adjustment Statement (PQAS) PQAS Form with Disclosure Statement_2017.pdf	Form

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-304a	Yes	Yes	Fillable Printable
Instruction		Yes	Yes	Fillable Printable
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 657

Number of Respondents for Small Entity: 60

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 85 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,628	188	2,440
Annual IC Time Burden (Hours)	73,584	5,264	68,320
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.

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