CMS-64 Payment detail Form Mockup
[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
2 CMS-64 Payment Detail Form Mockup 508
GenIC #73 (New): Supplemental Payment Reporting under the Consolidated Appropriations Act, 2021
OMB: 0938-1148
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1148 can be found here: