Information Collection Request

Reconciliation of State Invoice (ROSI) (CMS-304) and Prior Quarter Adjustment Statement (PQRS) (CMS-304a)

ICR 202403-0938-004 · OMB 0938-0676 · Received in OIRA

Forms and Documents

Document Name	Status
Form CMS-304a Prior Quarter Adjustment Statement (PQAS) (CMS-304a) Form	Modified
CMS-304_304a - Supporting Statement A (2024 version 6).docx Supporting Statement A	2024-03-07

IC Document Collections

IC ID	Document Title	Status
8261	Reconciliation of State Invoice (ROSI) (CMS-304) Instruction	Modified
46422	Prior Quarter Adjustment Statement (PQAS) (CMS-304a) Form	Modified
245951	CMS-304 and CMS-304a – One-Time System Updates	Removed

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-0676
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202102-0938-015
Agency Tracking No	CMCS
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31