View Information Collection (IC)

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GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021 CMCS
 
Unchanged
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-64 SPVNarr Mockup 1 CMS-64.SPVNarr Mockup.pdf Yes Yes Fillable Fileable
Form CMS-64 Payment detail Form Mockup 2 CMS-64 Payment Detail Form Mockup 508.pdf Yes Yes Fillable Fileable
Form CMS-64 Provider Info Mockup 3 CMS-64 Provider Info Mockup 508.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

54 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested 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 216 0 0 0 0 216
Annual IC Time Burden (Hours) 3,240 0 0 0 0 3,240
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SMDL: New Supplemental Payment Reporting and Medicaid Disproportionate Share Hospital Requirements under the Consolidated Appropriations Act, 2021 SMDL Supplemental DSH Payments_2021-11-19_clean.docx 12/08/2021
Generic Supporting Statement GenIC 73 - Generic Supporting Statement (2021 version 4).docx 12/08/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.