[MediaDent] - Dental Practice Management and Digital Radiography Software

Provider Enrollment: The majority of payers allow dentists to begin submitting electronic claims from day one. There are some, however, that require additional paperwork. This occurs most commonly with Medicaids as well as with Many Blue Cross Blue Shield Organizations.
Additional Enrollment: The following payers require additional enrollment for Providers to send electronic claims. Please be sure to read and follow the Instruction Sheet included for payer. Please click on the payer name for which you wish to download forms. Once you have downloaded the file, please print it and fill in the proper information as directed by the Instruction Sheet.

To view PDF files, you need Adobe Acrobat® Reader, available here:

Alabama Blue Cross Blue Shield

Alabama Medicaid

Alabama Medicaid Change of Tax Identification Number Only

Alaska Medicaid

Arkansas Blue Cross Blue Shield

Arkansas Blue Cross Blue Shield Change of Source Form only

Arkansas Medicaid

California Medicaid - CA Medicaid (Denti-Cal) forms are available for our direct vendors only. If you need this form, please call our office at (888) 255-7293 and verify your software vendor with us.

Colorado Medicaid

Connecticut Medicaid

Delaware Medicaid

Doral Dental

Florida Medicaid

Georgia Blue Cross Blue Shield

Georgia Medicaid

Idaho Blue Cross

Idaho Blue Shield

Idaho Medicaid

Illinois Blue Cross Blue Shield

Indiana Medicaid

Iowa Blue Cross (FEP claims only)

Iowa Blue Cross Blue Shield

Iowa Medicaid

John Deere

Kansas Blue Cross Blue Shield

Kansas Medicaid

Kentucky Medicaid

Kentucky Medicaid (Individual to Group Practice Change Only)

Louisiana Medicaid (EPSDT)

Louisiana Medicaid (ADULT)

Maine Medicaid

Massachusetts Blue Cross Blue Shield

Massachusetts Medicaid

Medical Mutual of Ohio

Michigan Medicaid - requires originals to be filled out and mailed in. Please contact Provider Enrollment if you require these forms.

Medical Mutual of Ohio

Minnesota Medicaid

Mississippi Medicaid

Missouri Medicaid

Montana Medicaid

New Hampshire Medicaid

New Jersey Blue Cross Blue Shield (Horizon Healthcare)

New Jersey Medicaid

New Mexico Medicaid

New York Medicaid

New York Medicaid - Trading Partner Agreement

North Carolina Medicaid - requires originals to be filled out and mailed in. Please contact Provider Enrollment if you require these forms.

North Dakota Dental Services (ND Blue Cross Blue Shield)

Ohio Medicaid

Oklahoma Medicaid

Oregon Blue Cross Blue Shield

Pennsylvania Medicaid

Rhode Island Blue Cross Blue Shield

Rhode Island Medicaid

South Carolina Medicaid

Tennessee Blue Cross Blue Shield

Texas Blue Cross Blue Shield

United Concordia

Vermont Medicaid

Washington Medicaid - requires triplicate originals to be filled out and mailed in. Please contact Provider Enrollment if you require these forms.

Virginia Medicaid

Washington Medicaid

West Virginia Medicaid

Wisconsin Blue Cross Blue Shield W-9 Form

Wisconsin Blue Cross Blue Shield

Wisconsin Medicaid

Wyoming Medicaid