Provider Forms

• If 30 days has passed since the date of the payment, verify with your bank to ensure the check was not cashed. Contact the Provider Services Call Center if the check was not cashed.
• If the Provider Services Call Center has determined the check has not been cashed, complete the Affidavit of Lost Warrant form and send via e-mail.
• Ask the agent for the warrant number for your reference. Once the signed affidavit is received, the accounting team will cancel the lost check and reissue in the Colorado interChange system.

• Institutional Certification - Effective February 1, 2008, this document must be completed and attached to all institutional claims submitted on the paper UB-04.
• Request for Reconsideration Form - Use these forms to submit claims for reconsideration when there are extenuating circumstances or mitigating factors that prevented compliance with filing requirements. The form(s) should be attached to the front or on top of the claim(s) and any related claim information.
  • Request for Reconsideration MEDICAL Form
  • Request for Reconsideration PHARMACY Form
• Certification for Delayed Eligibility Notification - This form is now obsolete, refer to the General Provider Information manual for updated timely filing policy details.
• Load Letter Request Form - For Retroactive/Delayed Eligibility Determinations
• Third Party Reporting Form - Complete this form when a client or his/her representative requests copies of bills for medical services paid by Colorado Medical Assistance Program.
• Refund to Health First Colorado or Returned Warrant Form - Use this form to submit Health First Colorado refund checks and returned warrants to the Department's fiscal agent.
• Request to Submit Paper Claims Form
• Pharmacy Refund Form
• Unlisted Procedure Code Form
• Manual Price Determination Form - Procedure Code 34839 - Attach the form to the claim via the Provider Web Portal.
• Non-Emergent Medical Transportation (NEMT) 25+ Mile Verification Form
• Non-Emergent Medical Transportation Standardized Trip Log
• Instructions for NEMT Standardized Trip Log
• Non-Emergent Medical Transportation Trip Log Addendum

Women's Health

• Certification Statement for Abortion to Save the Life of the Mother (07/23) - Complete and submit this form with the claim when billing for an abortion performed to save the life of the mother.
• Certification Statement for Abortion for Sexual Assault (Rape) or Incest (07/23) - Complete and submit this form with the claim when billing for an abortion due to sexual assault or incest.
• Acknowledgment/Certification Statement for a Hysterectomy (12/19) - Complete and submit this form with the claim when billing for a hysterectomy.
• Certification Statement Form for Non-Viable Pregnancies (7/23) - Complete and submit this form with the claim when billing for Mifeprex if used with an early pregnancy loss, miscarriage, or anembryonic service.

The following forms are for HCBS Service Providers who experience a critical incident involving a client enrolled under the following waiver programs, Brain Injury, Children's HCBS, Children with Autism, Consumer Directed Care, Elderly, Blind and Disabled, and Community Mental Health Supports,and need to report the critical incident to the SEP Agency Case Manager.

• Service Provider Critical Incident Reporting Form
• Service Provider Critical Incident Follow-Up Form

The form below is for RCCF, QRTP, and PRTF providers who experience a critical incident involving a member.

• Residential Provider Serious Incident Reporting Form

• Dental Certification - Effective October 1, 2005, this document must be completed and attached to all dental claims submitted on paper to the Department's Fiscal Agent.
• For all other forms related to dental: DentaQuest Colorado Medicaid Dental Program Provider ORM (07/14). (This above link will redirect to the DentaQuest Colorado Providers page. Please scroll down to the DentaQuest Resources section to find the link to the current ORM).

Print the relevant questionnaire from the list below and enter all requested information. All questions must be answered in order to make a Prior Authorization Request (PAR) determination. Unless another address is specified on the form, mail the completed form and the completed PAR to:

• Questionnaire #1 - Hospital Bed
• Questionnaire #2 - Pressure Relief Mattress
• Questionnaire #3 - Lift
• Questionnaire #4 - Seat Lift
• Questionnaire #5 - Standing Devices
• Questionnaire #6 - Pulse Oximeter
• Questionnaire #7 - Apnea Monitor
• Questionnaire #8 - CPAP/BiLevel (PAP)
• Questionnaire #9 - TENS or NMES
• Questionnaire #10 - Oral and Enteral Nutritional Formula Optional Submission on All PARs
• Questionnaire #11 - Adult Orthotics and Prosthetics
• Questionnaire #12 - Wound Closure Therapy
• Questionnaire #13 - Augmentative Communication Device
• Questionnaire #14 - Mechanical High Frequency Chest Wall Oscillation
• Questionnaire #15 - Wheelchair Tilt/Recline Device
• Questionnaire #16 - Oxygen Contents in Excess of 6 Liters Per Minute
• Questionnaire #17 - Power Seat Lift Component Only
• Questionnaire # 18 - Blood Pressure Unit/Monitor
• Health First Colorado Certificate of Medical Necessity for Oxygen Benefits
• Remote Therapeutic Monitoring

Visit the Federally Qualified Health Center Forms web page for related forms.

Fingerprint Criminal Background Check Other State/Medicare Information Form - Complete this form if fingerprints have been submitted and approved by Medicare or another State Medicaid Agency.

• Home Health Telehealth Form - Complete this form for clients who meet the criteria and may receive Telehealth services.
• Pediatric Assessment Tool

Visit the Long-Term Services and Supports Case Management Tools web page for related forms.

Visit the Pharmacy Resources web page for related documents and forms.

• 5615 Form - Updated February 2022
• Nursing Facility Post Eligibility Treatment of Income (PETI) Medical Necessity Certification Form and Checklist - Updated September 2022
• Nursing Facility PETI Activity Log - Updated February 2022
• Nursing Facility PETI Program Appeal Information - Updated February 2022
• Nursing Facility PETI Training

Visit the Physician-administered Drugs web page for related forms.

Medical PARs are submitted via the Acentra (formerly Kepro) Portal, Atrezzo. This includes PARs for supply, surgery, out of state, therapy, audiology, home health and pediatric behavioral therapy.

Visit the ColoradoPAR: Health First Colorado Prior Authorization Request Program web page or call 1-720-689-6340 for further information. Medical PARs are not submitted through the Provider Web Portal.

Home and Community Based Services (HCBS) waiver PARs are submitted by Case Managers via the Bridge.

If a PAR status shows as pending state review, providers are advised to contact the Provider Services Call Center to ensure the PAR was submitted via the correct method.

• Adult Long Term Home Health PAR Form (Effective 05/01/13) (Revised 7/11/24) - For providers submitting Adult Long Term Home Health (LTHH) PARs. As of June 1, 2013, this is the only Adult LTHH PAR form accepted by Health First Colorado (Colorado's Medicaid program).
• Change of Provider Form - Complete this form when a member has a current and active PAR with another provider.
• Colorado Fax Exemption Form - Use this form request an exception to the requirement to submit PARs via the Atrezzo PAR portal.
• Formulario de cambio de proveedor de Health First Colorado - Complete este formulario cuando un miembro tenga un PAR actual y activo con otro proveedor.
• Health First Colorado Prior Authorization (PAR) Outpatient Form - This form must be completed for services that require prior authorization. This form may be completed online, printed, and submitted to Kepro if the provider has been authorized to submit paper PARs. Do not use this form for Long Term Home Health, Private Duty Nursing, or EPSDT Extraordinary HH PARs.
• Health First Colorado Prior Authorization (PAR) Inpatient Form
• PDN Acuity Tool
• Non-Emergent Medical Transportation (NEMT) Out-of-State Prior Authorization Request (PAR) Form (10/27/21) - Complete this form to request authorization for NEMT service for members needing services out of state.

• Affidavit of Lawful Presence
• Attestation Form for Facilities Enrolling with Health First Colorado - RCCF/QRTP
• Backdate Enrollment Form - Do not submit any attachment with this form (such as a claim form). Note: The backdate form is only for fee-for-service billing. CHP+ and behavioral health providers need to contact their MCO/RAE to determine rules as they may have different restrictions. This form is not for affiliations, only new enrollments.
• Behavioral Therapy Provider Attestation Form
• Change of Ownership (CHOW) Form
• Disclosure Instructions EIN
• Disclosure Instructions SSN
• Doing Business As (DBA) Name Change Form - Do not mail to Gainwell Technologies. Follow instructions on the form to submit via the Provider Web Portal.
• Doula Provider Attestation Form
• Electronic Visit Verification Attestation Form
• Home Accessibility and Modifications Adaptation Form
• Legal Entity (Organization Type) Change Form - Do not mail to Gainwell Technologies. Follow instructions on the form to submit via the Provider Web Portal.
• Legal Name Change Form - Do not mail to Gainwell Technologies. Follow instructions on the form to submit via the Provider Web Portal.
• National Provider Identifier (NPI) Backdate Form - Do not mail to Gainwell Technologies. Follow instructions on the form to submit via the Provider Web Portal.
• Network Participation Verification Form - Instead of uploading a copy of the entire contract, providers can complete and upload this form to the Attachments and Fees page of the Online Provider Enrollment tool.
• Provider Application Fee Refund Request Form
• Provider Participation Agreement - Effective March 1, 2023 - Can only be signed from within the Online Provider Enrollment tool.
• EFT Exemption Instructions -  Used only for Case Managers, Out of State providers, and Colorado State Government Entities.
• RN Supervision Form
• W9 - Required for Taxpayer Identification Number (TIN) verification.

Visit the Provider Enrollment web page for more provider enrollment instructions and information.

Visit the Rural Health Center Forms web page for related forms.

• Consent to Sterilization - MED 178 (English) (06/16)
• Consentimiento a la Esterilización - MED 178 (English/Spanish combined form) (07/23)
• MED-178 Instructions (11/13)

• Synagis® Prior Authorization Request (PAR) Form

• Transition Coordination Participant Fact Sheet
  • Transition Services - Transition to Community Fact Sheet - Spanish
• Transition Coordination Process - Spanish
• Transition Coordination Referral Form
  • Transition Coordination Referral Form - Spanish
• Options Counseling Authorization for Release of Information
  • Options Counseling Authorization for Release of Information - Spanish
• Transition Coordination - Transition Options Form - Spanish
• Team Roles and Responsibilities - Spanish

Transition Documents

• Community Needs Assessment
  • Community Needs Assessment - Spanish
• Community Transition Participant Risk Agreement
  • Community Transition Risk Mitigation Plan-Participant Agreement - Spanish
• Community Transition Plan

Information & Reporting Forms

• Options Counseling Monthly Referral Report
• Third Party User Access Request Form (BUS & Bridge Access Form)

Housing Forms

The Department of Health Care Policy & Financing (the Department) has the ability to verify the social security number of clients who are submitting a HUD application, but do not have a social security card.  Refer to the DAL SSN verification form and the SSN verification form to learn about the process.

The Department works in partnership with the State of Colorado Division of Housing to administer housing vouchers for individuals transitioning from a long-term care facility.

Visit the Division of Housing web page for more information including application forms, guidance and training. Contact Kimberley Dickey at 303-864-7831 or Kimberley.Dickey@state.co.us for more information.

Visit the Transition Services web page for more information.