This field must be completed or the claim will be denied. All other fields should only be completed when applicable. Recipient Name Enter the recipient's last name first, first name, and middle initial as shown on the recipient's Medicaid card. Recipient Address Enter the recipient's street address. City Enter the recipient's city of residence.
State Enter the recipient's state of residence.
Sex Check the appropriate box. Phone Number Enter the recipient's phone number, if available. Zip Code Enter the recipient's zip code 17. When verifying the recipient's eligibility, verify if there is other insurance coverage. If applicable, enter the name of the dental insurance, their address, and the policy number.