Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-37)

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) -- (CMS-10529)

⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-37 Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-37) Form
CMS-37 Medicaid Program Budget Report 37 Blank Forms.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx Form
CMS-37 Medicaid Program Budget Report 37 Blank Forms.pdf mbescbesval0.medicaid.gov/MBESCBES/Default.aspx Form
CMS-37.3 Summary Medicaid Program Budget Report CMS- 37.3 Summary Form.pdf Form
CMS-37.3 Summary Medicaid Program Budget Report CMS- 37.3 Summary Form.pdf Form

Information Collection (IC) Details

IC Title:	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-37)	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
Form	CMS-37	Medicaid Program Budget Report	37 Blank Forms.pdf	https://mbescbesval0.medicaid.gov/MBESCBES/Default.aspx	Yes	Yes	Fillable Printable
Form	CMS-37.3 Summary	Medicaid Program Budget Report	CMS- 37.3 Summary Form.pdf		Yes	Yes	Fillable Fileable

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)	4,480	4,480
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.