Information Collection

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

IC 213568 under ICR 202101-0938-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-64 Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form
CMS-64 Medical Assistance Expenditures by Type of Service For t 64 Summary.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Form
CMS-64 Medical Assistance Expenditures by Type of Service For t 64 Summary.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Form
CMS-64 Unfilled Form 64 Blank Forms.pdf	Form
CMS-64 Unfilled Form 64 Blank Forms.pdf	Form

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: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
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

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	224	0	224
Annual IC Time Burden (Hours)	9,184	224	8,960
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.