State Agency Contact Form (CMS-368)

Medicaid Drug Rebate Program (MDRP): Quarterly State Invoice (CMS-R-144) and State Agency Contact Form (CMS-368)

OMB: 0938-0582

IC ID: 8197

Documents and Forms

Document Name Document Type
Form CMS-368 State Agency Contact Form (CMS-368) Form
CMS-368 State Agency Contact Form CMS-368 State Agency Contact Form_10.2021_Fillable_Final.pdf Form
CMS-368 State Agency Contact Form_Crosswalk_10.2021.pdf Crosswalk: Contact Form IC Document