Medical Service Providers can either use their own invoice or one of the medical or dental standard claim forms listed below.
Commonly Used Medical Service Claim Forms
The State of California accepts no responsibility for the content or accessibility of the external websites or external documents linked to on this website.
American Dental Association (ADA) - Dental Claim Form (PDF)
The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists and payers.
National Uniform Claim Committee – 1500 Health Insurance Claim Form (PDF)
The 1500 Claim Form is the basic paper claim form prescribed by many payers for claims submitted by physicians, other providers and suppliers.
*PLEASE NOTE: We are currently in the process of adding content to this section of the website, so please check back often if you cannot find what you are looking for, or feel free to contact us.
Who to Contact
To submit an invoice or if you have questions?
District mailing and email addresses and SPOC contacts
Have ideas to improve the guidelines webpage or materials? Send your suggestions to: DIAL@dor.ca.gov.