Paper Claim Form Examples
View instructions on how to fill out claim forms for Utah Medicaid. The below examples show proper placement of National Drug Code (NDC) information, National Provider Identifier (NPI), and Coordination of Benefits.
CMS-1500 (02-12) opens in a new tabCMS-1500 (08/05) opens in a new tab
UB-04 opens in a new tab
Dental opens in a new tab
Dental (ADA 2012) opens in a new tab