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

AZ Outpatient Medicaid Authorization Form

GA Medicaid Outpatient Prior Authorization Fax Form
GA HLD Form

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

IL HFS 3365 - HLD Form (PDF) (Blank Fillable PDF )

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

MS Benefit Limit Exemptions Form (BLE)

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

WI 508 MHS Outpatient Mediciad Prior Authorization Form

Fequently Asked Questions

IN Outpatient Medicaid Prior Authorization Form (508 IHCP Universal)

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

MO Medicaid Outpatient Prior Authorization Fax Form

NE Medicaid Outpatient Prior Authorization Fax Form (PDF)
NE HLD Form (PDF)

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

PA Benefit Limit Exemptions Form (BLE)