Institutional Certification  - Effective February 1, 2008, this document must be completed and attached to all institutional claims submitted on the paper UB-04.

Colorado 1500 Claim Form    This form must be completed when submitting charges that are billable on the paper Colorado 1500 claim form. By completing and signing the Colorado 1500 claim form, the provider agrees to all terms described in the Colorado 1500 Certification.

Colorado 1500 Interactive Claim Form  - This form can be completed online. Once completed, the form can be printed, signed and mailed to the Xerox State Healthcare at P.O. Box 30, Denver, CO 80201. By completing and signing the Colorado 1500 claim form, the provider agrees to all terms described in the Colorado 1500 Certification.

EPSDT Claim Form - This form must be completed when submitting charges that are billable on the paper EPSDT claim form. By completing and signing the EPSDT claim form, the provider agrees to all terms described in the EPSDT Certification.

Adjustment Transmittal Form with Instructions - Use this form to adjust paid claims only.

Request for Reconsideration Form - Use this form 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.

Acknowledgment/Certification Statement for a Hysterectomy - Complete and submit this form with the paper claim when billing for a hysterectomy.

Certification & Request for Timely Filing Extension - Delayed Eligibility Notification - Complete and submit this form with the paper claim when billing for service dates outside of timely filing due to delayed notification.

Certification Statement for Abortion to Save the Life of the Mother - Complete and submit this form with the paper claim when billing for an abortion performed to save the life of the mother.

Certification Statement for Abortion for Sexual Assault (Rape) or Incest - Complete and submit this form with the paper claim when billing for an abortion due to sexual assault or incest.

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.

The following forms are for HCBS Service Providers and SEP Agency Case Managers 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, Mental Illness and People Living with AIDS.

Provider Critical Incident Reporting Form

Critical Incident Follow-Up Form

Dental Certification - Effective October 1, 2005, this document must be completed and attached to all dental claims submitted on paper.

Dental Assistant Surgeon Report Form  - This form must be completed and submitted with the paper claim form for all dental assistant surgery procedures.

2009 Handicapping Malocclusion Assessment Form - Complete this form and submit it with all supporting diagnostic and radiographic services used to determine and fully diagnose the client's condition. Submit all documentation and the dental claim to Colorado Medicaid.

Dental Risk Assessment Form

Medical Risk Assessment Form

For enrollment forms and information, please go to the Enrollment page.

To download an application: Click on Enrollment on the left menu bar; then click on Providers not yet enrolled; select your specialty and download the November 2010 version of the Provider Participation Agreement. As of March 1, 2011, the Department’s fiscal agent will only accept the November 2010 version of the Provider Application. All other versions of the application will be returned to the provider.

Lawful Presence Verification August 2006 - This document contains additional information about complying with C.R.S. § 24-76.5-103 (verifying the lawful presence in the United States). It also contains the "REQUEST FOR WAIVER RESTRICTIONS ON PUBLIC BENEFITS" form.

Provider Enrollment Update Form - Follow the instructions on the form to update your provider information.

Electronic Provider Enrollment Update Form - This new electronic Enrollment Update form can be completed online, printed, and mailed to Xerox State Healthcare, P.O. Box 1100, Denver, CO 80201-1100.

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

Pediatic Home Health Assessment Tool

Medical Necessity Certification Form - Dental Services Criteria 

Medical Necessity Certification Form - Eyeglasses (Corrective Lenses) Criteria  

Medical Necessity Certification Form - Health Insurance Premiums, Deductibles, or Coinsurance Medical Criteria 

Medical Necessity Certification Form - Hearing Aid and Other Audiology Criteria     

Nursing Facility PETI Program Request Form 

Nursing Facility PETI Program Appeal Information  

All Pharmacy forms, including prior authorization forms, can be accessed from the Pharmacy Billing Procedures and Forms Web page.

The PAR Status Inquiry in the Colorado Medical Assistance Web Portal (Web Portal) allows providers to make PAR status inquiries about all PAR types. Please review the online Training, User Guide, and the Help feature for additional information.

Submit all PARs to the appropriate Authorizing Agency listed in Appendix D of the Billing Manuals Appendices section.

Colorado Medical Assistance Program Prior Authorization (PAR) Form  - This form must be completed for Medical Assistance Program services requiring prior authorization. Do not use this form for Long Term Home Health, Private Duty Nursing, EPSDT Extraordinary HH PARs. Please use the Long Term Home Health, Private Duty Nursing, EPSDT Extraordinary HH Prior Authorization Request (PAR) form listed below.

Electronic Prior Authorization (PAR) Form - This new electronic Medicaid Prior Authorization (PAR) form can be completed online, printed, and submitted to the Authorizing Agency listed in Appendix D of the Billing Manuals Appendices section.

Adult Long Term Home Health PAR Form (Effective 05/01/13) (Revised 05/07/13) - 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 the Colorado Medicaid Program.

Colorado Choice Transitions (CCT) PAR Forms (11/12) - All CCT PAR forms are located on the CCT Web page.

HCBS PAR Forms-BI, CMHS, EBD, PLWA, CHCBS, CLLI, and CWA (Effective 3/4/13) (Revised 04/10/13) - Click on the Waiver type tab at the bottom of the page to access the program's PAR form.

PDN Acuity Tool

Medicaid PDN Application

 Consent to Sterilization - MED 178 (English) 

 Consentimiento Para Esterilizacion - MED 178 (Spanish)  

Change of Provider Form - Complete this form when a client has a current and active PAR with another provider.

CLIA Update Form  - Complete this form if you are a laboratory provider enrolled in the Colorado Medical Assistance Program and need to update or change your CLIA information.

EDI Update Form  - Complete this form if you are enrolled in the Colorado Medical Assistance Program and enrolled for the Web Portal and need to update or change your EDI information..

PCP (Primary Care Physician) Application  - Complete this form if you would like to participate in the Primary Care Physician Program.

PCP Contract   - Complete this form if you would like to participate in the Primary Care Physician Program. Please download, complete and mail the form(s) to:

Xerox State Healthcare
Provider Enrollment
P.O. Box 1100
Denver, CO 80201-1100

PCP Update Form  - Providers with location, billing or mail-to address changes and/or PCP changes need to complete, sign and submit this form to Xerox State Healthcare, Provider Enrollment, PO Box 1100, Denver, CO 80201-1100.

5615 Form

EFT  - Authorization Agreement for Automatic Deposits form. Complete this form to receive Medical Assistance Program payment by Electronic Funds Transfer. Completion of this form is required.

Email Op-Out Form - Use this form to opt-out of Medical Assistance Program email notifications.

Forms Requisition Form  - Medical Assistance Program claim forms may be ordered from the fiscal agent by completing and mailing this form to the fiscal agent.

Load Letter Request Form - Use this form to request a Load Letter from the Department.

Prenatal Plus Program Participation Form - Complete this form to participate in the Prenatal Plus Program.

Provider Overuse, Fraud and Abuse Referral Form - Use this form to report suspicion of provider fraud, waste, or abuse in the Colorado Medical Assistance Program, Managed Care Organizations (MCO), Behavioral Health Organizations (BHO) and Children’s Health Program Plus (CHP+).

Publication Email Preference Form - Complete this form to specify how you will receive emails containing important notifications (including time-sensitive information) and bulletin links from the Colorado Medical Assistance Program. Only one email address per provider may be on file.

Refund to Medicaid or Returned Warrant Form - Use this form to submit Medicaid refund checks and returned warrants to the Department's fiscal agent. 

Trading Partner ID Termination  - This form must be completed when requesting the termination of your Trading Partner ID. Complete and submit the form according to the instructions on the form.

W9  - This form is required for Taxpayer Identification Number verification.