Claim and Adjustment Forms Description
209-EPSDT Dental Adjustment/Void Form & Instructions (Rev 02/20)
(PDF Format)
This form is used to submit EPSDT Dental claim adjustments and voids.
210-Adult Dental Adjustment/Void Form & Instructions (Rev 02/20)
(PDF Format)
This form is used to submit Adult Dental claim adjustments and voids.
211 - Drug Adjustment Form (Rev 11/16)
(PDF Format)
This form is used to submit pharmacy claim adjustments, voids, and DUR overrides.