CMS-64 Provider Info Mockup

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

Supplemental Payment Validaton Providers (CMS 64.SPVProvider)
List of Providers Receiving Supplemental Payments

Provider Name

Medicaid ID

NPI

Medicare ID

Other State ID

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

Ownership Category

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.