Information Collection

GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021

IC 250720 under ICR 202401-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-64 GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021	Form
Form CMS-64 GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021	Form
CMS-64 SPVNarr Mockup 1 CMS-64.SPVNarr Mockup.pdf	Form
CMS-64 SPVNarr Mockup 1 CMS-64.SPVNarr Mockup.pdf	Form
CMS-64 Payment detail Form Mockup 2 CMS-64 Payment Detail Form Mockup 508.pdf	Form
CMS-64 Payment detail Form Mockup 2 CMS-64 Payment Detail Form Mockup 508.pdf	Form
CMS-64 Provider Info Mockup 3 CMS-64 Provider Info Mockup 508.pdf	Form
CMS-64 Provider Info Mockup 3 CMS-64 Provider Info Mockup 508.pdf	Form
SMDL Supplemental DSH Payments_2021-11-19_clean.docx SMDL: New Supplemental Payment Reporting and Medicaid Disproportionate Share Hospital Requirements under the Consolidated Approp	IC Document
SMDL Supplemental DSH Payments_2021-11-19_clean.docx SMDL: New Supplemental Payment Reporting and Medicaid Disproportionate Share Hospital Requirements under the Consolidated Approp	IC Document
GenIC 73 - Generic Supporting Statement (2021 version 4).docx Generic Supporting Statement	IC Document
GenIC 73 - Generic Supporting Statement (2021 version 4).docx Generic Supporting Statement	IC Document

IC Title:

GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021

Agency IC Tracking Number:

CMCS

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-64	SPVNarr Mockup	1 CMS-64.SPVNarr Mockup.pdf	Yes	Yes	Fillable Fileable
Form	CMS-64	Payment detail Form Mockup	2 CMS-64 Payment Detail Form Mockup 508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-64	Provider Info Mockup	3 CMS-64 Provider Info Mockup 508.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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
	Requested	Previously Approved
Annual Number of Responses for this IC	216	216
Annual IC Time Burden (Hours)	3,240	3,240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SMDL: New Supplemental Payment Reporting and Medicaid Disproportionate Share Hospital Requirements under the Consolidated Appropriations Act, 2021	SMDL Supplemental DSH Payments_2021-11-19_clean.docx	12/08/2021
Generic Supporting Statement	GenIC 73 - Generic Supporting Statement (2021 version 4).docx	12/08/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.