Nevada Medicaid coordination of benefits form

If you have other insurance that includes dental benefits, please complete the form below.

Items marked with * are required fields.

Nevada Medicaid member first name

Nevada Medicaid member last name

Nevada Medicaid ID number

Name of other insurance company

Other insurance address/phone

Name of family member insured through them

Relationship of family member to Nevada Medicaid member

Effective date of other coverage

Group, policy, and member numbers of other coverage

Type of other coverage

Last Updated: 12/22/2021