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

(CMS-10529) Quarterly Medicaid and CHIP Budget and Expenditure Reporting for the Medical Assistance Program, Administration and CHIP (MBES/CBES Forms CMS-21 and -21B, -37, and -64)

OMB: 0938-1265

IC ID: 213568

Information Collection (IC) Details

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Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-64 Medical Assistance Expenditures by Type of Service For the Medical Assistance Program 64 Summary.pdf https://mbescbesval0.medicaid.gov/MBESCBES/Default.aspx Yes Yes Fillable Printable
Form CMS-64 Unfilled Form 64 Blank Forms.pdf Yes Yes Fillable Printable

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) 9,184 0 224 0 0 8,960
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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