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Federal forms, ICRs, and supporting documents

Information Collection

Reconciliation of State Invoice (ROSI) (CMS-304)

IC 8261 under ICR 202403-0938-004 · OMB 0938-0676.

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Reconciliation of State Invoice (ROSI) (CMS-304)
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_07.2021_508.pdf Yes No Fillable Printable
Form CMS-304 Reconciliation of State Invoice (ROSI) CMS Form-304 Reconciliation of State Invoice (ROSI)_07.2021_508.pdf Yes Yes Fillable Printable
Instruction CMS Form-304 Reconciliation of State Invoice (ROSI)_Electronic Format_07.2021_508.pdf Yes Yes Fillable Printable
Instruction Adjustment and Dispute Codes for CMS-304_304a_07.2021_508.pdf Yes No Printable Only

Health Health Care Services

 

571 41
   
Private Sector Businesses or other for-profits
 
   85 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,284 0 0 188 0 2,096
Annual IC Time Burden (Hours) 159,880 0 0 13,160 0 146,720
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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