- SSN only
- Must affiliate to a billing/direct pay entity
The provider type you have selected indicates you should complete the Rendering Provider Application.
Rendering Provider Application enrollment requires a SSN only. A rendering provider is the individual that provides services to a Colorado Medicaid member. The rendering provider must affiliate with a clinic/facility that will submit claims and provide reimbursement to the individual.
If an individual has obtained an EIN to identify as a business entity, both a rendering and a standard application may need to be completed. For instance a dentist will need to enroll once as a rendering provider (using his/her SSN) to provide services to the Colorado Medicaid member, and as a dental clinic (using the EIN) to complete the Standard Provider Application to submit claims.
|Certified Registered Nurse Anesthetist|
|Psychologist (PhD or MA)|
|Registered Nurse||→ Supervision Form (04/14)|
For further assistance please contact: Xerox State Healthcare Provider Services Call Center 1-800-237-0757