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Prior Quarter Adjustment Statement (PQAS) (CMS-304a)
Reconciliation of State Invoice (ROSI) (CMS-304) and Prior Quarter Adjustment Statement (PQRS) (CMS-304a)
OMB: 0938-0676
IC ID: 46422
OMB.report
HHS/CMS
OMB 0938-0676
ICR 202403-0938-004
IC 46422
( )
Documents and Forms
Document Name
Document Type
Form CMS-304a
Prior Quarter Adjustment Statement (PQAS) (CMS-304a)
Form
CMS-304a Prior Quarter Adjustment Statement (PQAS)
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_07.2021_508.pdf
Form
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Electronic Format_07.2021_508.pdf
Instruction
Adjustment and Dispute Codes for CMS-304_304a_07.2021_508.pdf
Instruction
CMS Form-304a Prior Quarter Adjustment Statement (PQAS)_Instructions_07.2021_508.pdf
Instruction
Information Collection (IC) Details
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