CMS-64 Payment detail Form Mockup

OMB No. 0938-1148 (CMS-10398 #73)

Supplementals Payment by Provider (CMS 64.SPVPayment)

State: Alabama
Agency: CMS
.
Quarter/Year: Qtr 4th 2021
Quarter Ended: 9/30/2021

List of Supplemental Payments by Provider and CMS-64 form

Provider Name / Medicaid ID

Service Type

Form

Expediture Type

Waiver Information

Prior Period Information

Program

Amount

PRA Disclosure Statement The purpose of this collection of information is to collect information on all supplemental payments from Medicaid programs. This collection is mandatory and based on statue- passage of Division CC, Title
II, Section 202 of the CAA, Congress added subsection (bb) to section 1903 of the Act, which requires the Secretary of Health and Human Services to establish a system for states to submit reports on supplemental payments as
defined in section 1903(bb)(2) of the Act, no later than October 1, 2021. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1148 (CMS-10398 #73). The time required to complete this information collection is estimated to average 15 hours per quarter per state (60 hours per year per state) per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.