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
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| Form 600 |
Provider self-audit form and instructions |
| REF-02 |
Check Refund Form (providers only) |
| Form ADJ-02 |
Adjustment Request Form (providers only) |
| Form 402 |
Request for Medical Utilization Redetermination Second Appeal |
| Form 403 |
Request for NCCI Administrative Review |
| Form 404 |
Request Review of Outdated Medicaid Claim |
| Gainwell-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
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| Form 3P-2 |
Fillable form to report changes in insurance coverage |