Provider Forms & Documents

Billing

This page provides all forms and documentation for providers billing UOVC, including treatment plans, dental forms, billing forms, and payment setup.

Mental Health Treatment Plans

Adults

Minors

Common Billing Forms

CMS-1500 Billing Form

UB-04 Billing Form

ADA Dental Claim Form

Fast Track Reimbursement Form – SA Services Providers

Receiving Payment / Vendor Setup

New vendors (never paid by the state) → New Vendor FI-170 + W-9

All vendors setting up Direct Deposit/EFT → EFT FI-171