Billing/Provider Forms

A variety of online and paper forms are available to applicants, recipients and sponsors.  For help in applying for Medicaid, contact 1-800-362-1504.


Administrative Forms
Self-Audit Provider self-audit notification of intent
Self-Audit Options Options for conducting a self-audit and expediting the return of overpayments to Medicaid
Self-Audit Instructions Required documents, format and where to send information, along with payment
REF-02 Check Refund Form (providers only)
Form ADJ-02 Adjustment Request Form (providers only)
Form 404 Request Review of Outdated Medicaid Claim
Form 403 Request for NCCI Administrative Review
HPE-Redetermination Request Request for NCCI Redetermination Review
Form 265 To request infant/child's Medicaid Number (providers only)
Form 284 Newborn Certification - to enroll children of Medicaid Eligible mothers in Medicaid from birth until their first birthday
Third Party Benefit Coordination Forms
Online HIPP Application Go online to apply for Medicaid's Health Insurance Premium Payment program (HIPP)
Form 3P-1 Fillable form to request Medical Records
Form 3P-2 Fillable form to report changes in insurance coverage