Rendering App

Rendering Application

  • SSN only
  • Must affiliate to a billing/direct pay entity

The provider type you have selected indicates you should complete the Rendering Provider Application.

Download the Rendering Provider Application by clicking this link


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.

Provider Type

Additional Documentation

Certified Registered Nurse Anesthetist  
Dental Hygienist  
NEMT Transportation (for providers in Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer, and Weld counties) For important enrollment information for NEMTproviders in the listed nine (9) counties, please see the Transportation Broker's website.
Nurse Practitioner  
Occupational Therapist  
Physical Therapist  
Physician Assistant  
Psychologist (PhD or MA)

 Important enrollment information for behavioral health services

Registered Nurse Supervision Form (07/15)
 Speech Therapist  

For further assistance please contact: Xerox State Healthcare Provider Services Call Center 1-800-237-0757