Information Collection

Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)

IC 213568 under ICR 202404-0938-020 · OMB 0938-1265.

Documents and Forms

Document Name Document Type
Form CMS-64 Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64) Form
CMS-64 Medical Assistance Expenditures by Type of Service For t CMS-64 Forms 508 Compliant.pdf Form
CMS-64 Medical Assistance Expenditures by Type of Service For t CMS-64 Forms 508 Compliant.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-64	Medical Assistance Expenditures by Type of Service For the Medical Assistance Program	CMS-64 Forms 508 Compliant.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	224	224
Annual IC Time Burden (Hours)	9,184	9,184
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.