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