Information Collection

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

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-304 Reconciliation of State Invoice (ROSI) Reconciliation of State Invoice (ROSI) (CMS-304)	Form
CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_07.2021_508.pdf	Instruction
CMS Form-304 Reconciliation of State Invoice (ROSI)_Instructions_07.2021_508.pdf	Instruction
CMS Form-304 Reconciliation of State Invoice (ROSI)_Electronic Format_07.2021_508.pdf	Instruction
CMS Form-304 Reconciliation of State Invoice (ROSI)_Electronic Format_07.2021_508.pdf	Instruction
Adjustment and Dispute Codes for CMS-304_304a_07.2021_508.pdf	Instruction
Adjustment and Dispute Codes for CMS-304_304a_07.2021_508.pdf	Instruction
CMS-304 Reconciliation of State Invoice (ROSI) CMS Form-304 Reconciliation of State Invoice (ROSI)_07.2021_508.pdf	Form
CMS-304 Reconciliation of State Invoice (ROSI) CMS Form-304 Reconciliation of State Invoice (ROSI)_07.2021_508.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Fillable Printable
Form	CMS-304	Yes	Yes	Fillable Printable
Instruction		Yes	Yes	Fillable Printable
Instruction		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 571

Number of Respondents for Small Entity: 41

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 85 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,284	188	2,096
Annual IC Time Burden (Hours)	159,880	13,160	146,720
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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