Information Collection

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

IC 213568 under ICR 202611-0938-007 · OMB 0938-1265.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-64 (Series) Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (CMS-64)	Form
CMS-64 (Series) Medical Assistance Expenditures by Type of Service For t CMS-64 Forms 508 Compliant.pdf	Form
CMS 64 Summary.pdf CMS-64 Summary	IC Document
CMS-64.9.O.pdf CMS-64.9O	IC Document
CMS 64.11.pdf CMS-64.11	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-64 (Series)				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 %

table that charts list of burden
	Requested	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

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

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