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Provider Resources

Medicaid Forms

Find relevant forms by state.

Outpatient authorization: If taking a patient to a hospital for dental treatment, some providers must submit the outpatient authorization form. These forms are maintained by the health plan, but you can access the form for your state below. Instructions for submission are located at the top of the form (e.g., a fax number or additional options to submit).
BLE: Benefit Limit Exemptions (BLE) summary request forms (MS, PA only)
Orthodontic forms: Coming soon

AZ Outpatient Medicaid Authorization Form

IN Outpatient Medicaid Prior Authorization Form (508 IHCP Universal)

MO Medicaid Outpatient Prior Authorization Fax Form

MO HLD Form (Fillable PDF) (PDF with Instructions)

NM Outpatient Medicaid Authorization Form (NM-PAF-5846)

PA Outpatient Medicaid Prior Authorization Form (PA-PAF-1138)

PA Benefit Limit Exemptions Form (BLE)

GA Medicaid Outpatient Prior Authorization Fax Form

IL Outpatient Medicaid Prior Authorization Form (IV-PAF-6149)

IL HFS 3365 - HLD Form (dynamic version must download)

KS Outpatient Medicaid Authorization Form (KA-PAF-0674)

MS Outpatient Medicaid Prior Authorization Form (MS-PAF-0618)

MS Benefit Limit Exemptions Form (BLE)

WI 508 MHS Outpatient Mediciad Prior Authorization Form