Resources for our Medicaid providers

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.
  • BLE: Benefit Limit Exemptions (BLE) summary request forms (MS, PA only)
  • Orthodontic forms