DMAS ICF Map 128 SFY 2022

Primary Account Holder (PAH) Request Form

Primary Account Holder Request Form (PDF)
Providers who need to assign a primary account holder to their account at the tax identification number level must complete and submit a PAH change form.
Please submit only one form
How Do I Complete the Form?
You can download the instructions here (PDF), or
learn from the new PAH video.

DMAS ICF Map 128 SFY 2022

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Cost report form for Intermediate Care Facility (this report will need to be replaced annually)

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DMAS ICF Map 128 SFY 2022