Individual Carrier Enrollment Forms:

Below is a list of insurance carriers that require an additional enrollment form to be returned prior to submitting electronic claims. In addition to submitting the appropriate SIGN-UP form (located above), you may need to also complete one or more of the enrollment forms below if you submit to any of these carriers. Print the appropriate form(s) and fax them directly to the CARRIER (not to the QUIC Department).

Alabama Blue Cross Blue Shield Alabama Medicaid Arkansas Blue Cross Blue Shield Cigna Dental Health Colorado Medicaid Colorado Medicaid EDI Update Connecticut Medicaid Denti-Cal Doral Dental Florida Medicaid Georgia Medicaid Group Health Managers Health Choice Inc. Idaho Blue Cross Idaho Blue Shield Idaho Medicaid Indiana Medicaid Iowa Blue Cross Blue Shield Iowa Delta Dental Iowa Medicaid Kentucky Medicaid LifeWise/Washington Employers Trust Louisiana Medicaid Maine Medicaid Massachusetts Blue Cross Blue Shield Massachusetts Medicaid Michigan Medicaid Minnesota Delta Dental Minnesota Medicaid Mississippi Medicaid Missouri Medicaid Nebraska Delta Dental New Hampshire Medicaid New Jersey Direct Dental New Jersey Medicaid New Jersey Medicaid 835 EDI Agreement New Jersey Medicaid 837EDI Electronic Claims Input New York Medicaid North Carolina Medicaid North Dakota Blue Cross Blue Shield North Dakota Delta Dental Ohio Blue Cross Blue Shield Ohio Medicaid Oklahoma Medicaid Oregon Blue Cross Blue Shield Pennsylvania Blue Cross Blue Shield Pennsylvania Medicaid Regency Employee Benefits Rhode Island Blue Cross Blue Shield Rhode Island Medicaid Southern Group Administrators Tennessee Blue Cross Blue Shield Tennessee Medicaid Texas Blue Cross Blue Shield United Concordia (UCCI) Vermont Medicaid Washington Medicaid West Virginia Medicaid Wisconsin Blue Cross Blue Shield Wisconsin Medicaid Wyoming Delta Dental Wyoming Medicaid