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
Form 600 Provider self-audit form and instructions
REF-02 Check Refund Form (providers only)
Form ADJ-02 Adjustment Request Form (providers only)
Form 401 Request for Medical Utilization Redetermination First Appeal
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Form 404 Request Review of Outdated Medicaid Claim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
Form 3P-2 Fillable form to report changes in insurance coverage