Forms
For enrollment forms and information, please go to the Enrollment page.
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.
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. Effective March 1, 2011, ACS will only accept the November 2010 version of the Provider Application. All other versions of the application will be returned to the provider.
All Pharmacy forms, including prior authorization forms, can be accessed from the Pharmacy Home Page .
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 ACS 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
Claim Forms
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 Reporting System Forms
| Dental Forms | |
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.
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PAR submissions for Dental Care, Medical Care and Supply can be made through the Colorado Medical Assistance Program Web Portal. Up to 25 detail lines may be submitted through the Web Portal directly to the Medicaid Management Information System. The PAR Status Inquiry 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. 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 mailed to ACS, P.O. Box 30, Denver, CO 80201-0030. Long Term Home Health PAR Form - All providers submitting PARs for Long Term Home Health, Private Duty Nursing, and EPSDT Extraordinary HH must complete this form. Beginning December 1, 2011, this is the only LTHH PAR form accepted by the Colorado Medicaid Program. Request for HCBS Prior Approval and Cost Containment for HCBS-BI form - This document contains procedure codes, descriptions and completion instructions. Providers should download the form as needed and begin using it immediately. HCBS Cost Containment/Authorization Process Diagram REQUEST FOR ADULT HCBS PRIOR APPROVAL AND COST CONTAINMENT FOR HCBS -EBD, -MI, AND -PLWA form - This is a new Prior Approval form for adult HCBS services and contains procedure codes, descriptions and completion instructions. Providers should download the form as needed and begin using it immediately. REQUEST FOR CHILD HCBS PRIOR APPROVAL AND COST CONTAINMENT FOR HCBS -CWA, -CHCBS, AND -PHW form - This is a new Prior Approval form for child HCBS services and contains procedure codes, descriptions and completion instructions. Providers should download the form as needed and begin using it immediately. Synagis® Information Sheet and Synagis® Prior Authorization Request Form - Synagis® (Palivizumab) prior authorization requests must be submitted on the Colorado Medicaid Synagis Prior Authorization Request (PAR) form. Please see the Synagis® Information Sheet for additional PAR information.
Prior Authorization Request Forms
| Sterilization Consent Forms | |
Consent to Sterilization - MED 178 (English) Consentimiento Para Esterilizacion - MED 178 (Spanish) |
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. 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 ACS, P.O. Box 1100, Denver, CO 80201-1100.
Update Forms
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: ACS State Healthcare Colorado Medical Assistance Program 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 Medical Assistance Program Provider Enrollment, PO Box 1100, Denver, CO 80201-1100.
PCP Forms
Adjustment Transmittal Form with Instructions - Use this form to adjust paid claims only. Add-A-Baby Form (Fill-in) - Use this form to report thith Ie birth of a child born to a Medicaid or CHP+ client via email. Add-A-Baby Form (Print and Fax) - Use this form to report the birth of a child born to a Medicaid or CHP+ client via fax or mail. Certificate for Medical Necessity for Oxygen Benefits - This form must be used by nursing facilities to certify oxygen use for clients. 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. Home Health Telehealth Form - Complete this form for clients who meet the criteria and may receive Telehealth services. Load Letter Request Form - Use this form to request a Load Letter from the Department. Out-of-State Pharmacy Letter - All out-of-state pharmacies must complete and return this letter with their Medical Assistance Program Provider Application. 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 Fiscal Agent. 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. 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.
Other Forms