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Federal forms, ICRs, and supporting documents

Information Collection

Quarterly Utilization Report (CMS-R-144)

IC 212418 under ICR 201704-0938-011 · OMB 0938-0582.

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Instruction
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Quarterly Utilization Report (CMS-R-144)
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction CMS-R-144 Data Definitions_2017.pdf Yes No Printable Only
Instruction Invoice Process Instructions_Clean_05.08.17.docx Yes No Printable Only
Form CMS-R-144 Medicaid Drug Rebate Invoice CMS-R-144 with Disclosure Statement_2017.pdf Yes Yes Fillable Printable
Instruction CMS-R-144 Record Layout_2017.pdf Yes Yes Printable Only

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 224 0 0 0 0 224
Annual IC Time Burden (Hours) 12,096 0 0 0 0 12,096
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk - Invoice Process Instructions Invoice Process Instructions_TC_05.08.17.docx 06/21/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.