Health First Colorado Add-A-Baby Emergent Request Form

This page is for providers to submit an emergent request to add a baby to an existing Health First Colorado (Colorado’s Medicaid Program) case. An emergent request is only for babies who need intensive medical attention for Border, SYNAGIS, or Neonatal Intensive Care Unit (NICU).

For all other requests to add a baby to a Health First Colorado case:

Before submitting an Emergent Request

Please inform the parent(s) that you are submitting a request to HCPF to add the newborn.
Ensure that the parent(s) have not already submitted newborn information to the county or through PEAK before you submit your request.
Multiple applications will cause a delay in approval of benefits and delay provider payments.

Instructions

Complete all fields. Fields with * are required.
CHECK FOR ACCURACY BEFORE YOU CLICK SUBMIT AT THE BOTTOM. Errors may delay or eliminate the ability to process your request.
DO NOT SUBMIT A DUPLICATE REQUEST. If the newborn baby is not showing as eligible in 15 days send an email to add-a-baby@state.co.us. Please use the mother's State ID when inquiring.
Complete the "Add Additional Baby" section on the form if you are requesting to add twins.

Information About Mother

Mother's First Name *

Mother's Last Name *

Address *

Address2

Is this a new address within the last six months?

Yes

City *

State *

Zip Code *

County *

Phone Number *

Email Address

Mother's Date of Birth *

Year

Month

Day

State ID *

A State ID is the state identification number an individual is assigned when approved for Medical Assistance. It consists of a letter followed by a six-digit number. It is also referred to as a Health First Colorado (Colorado Medicaid) ID number and can be found on the Medical Identification Card (MIC). Example: D999999

Case Number

A case number is assigned when an individual submits an application for public assistance. It consists of seven characters and begins with 1B. It is also referred to as a CBMS Case ID and can be found on county/state paperwork such as an approval or denial notice. Example: 1B99999

Information About Newborn Baby

NOTE: The newborn baby's information must be the same as it appears on the birth certificate application.

Baby's First Name *

Baby's Middle Name

Baby's Last Name *

Baby's Suffix

Gender *

Baby's Date of Birth *

Year

Month

Day

Add Additional Baby

Baby 2's First Name

Baby 2's Middle Name

Baby 2's Last Name

Baby 2's Suffix

Baby 2's Gender

Baby 2's Date of Birth

Year

Month

Day

Are you a Medical Provider?

Yes

IS THIS AN EMERGENT REQUEST?

Yes

Reason For Request *

Information About Submitter

Submitter's Name

Submitter's Email Address

Submitter's Phone Number

Coronavirus Disease 2019 (COVID-19) in Colorado: State & National Resources

Health First Colorado Add-A-Baby Emergent Request Form

Information About Mother

Information About Newborn Baby

Add Additional Baby

Information About Submitter