View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program	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	Quarterly Medicaid Assistance Expenditures For the Medical Assistance Program	CMS 64 Forms.pdf		Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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	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	224	0	0	0	0	224
Annual IC Time Burden (Hours)	18,144	0	0	0	0	18,144
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Copy of CMS-64_-_Crosswalk.xlsx	05/24/2013
Disclosure Statement	CMS-64 Disclosure Statement.doc	05/24/2013
64 9 form	64 9 form.docx	06/13/2013
64 10 screen	64 10 screen.docx	06/13/2013

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