View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Prior Quarter Adjustment Statement (PQAS) (CMS-304A)
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-304a Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes No Printable Only
Instruction Yes No Printable Only

Health Health Care Services

 

738 60
   
Private Sector Businesses or other for-profits
 
   85 %

  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 2,952 0 0 324 0 2,628
Annual IC Time Burden (Hours) 82,656 0 0 9,072 0 73,584
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Track Change - Prior Quarter Adjustment Statement (PQAS) 03/17/2020
Track Change - Electronic Format 03/17/2020
Crosswalk - Adjustment and Dispute Codes 03/31/2020
Track Change - Adjustment and Dispute Codes 03/17/2020
Crosswalk - Instructions 03/17/2020
Track Change - Instructions 03/17/2020
Crosswalk - Prior Quarter Adjustment Statement (PQAS) 03/31/2020
Crosswalk - Electronic Format 03/31/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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