CMS-10398 #24 UPL Institute Mental Disease Template 1
Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
24 - XI - UPL-Institute-Mental-Disease Template 1.xlsx
GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers
OMB: 0938-1148
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1148 can be found here: