Provider Forms

Accounting
  • If 30 days has passed since the date of the payment, verify with your bank to ensure the check was not cashed. Contact the Provider Services Call Center if the check was not cashed.

    If the Provider Services Call Center has determined the check has not been cashed, complete the Affidavit of Lost Warrant form and mail to:

Department of Health Care Policy & Financing
Accounting Department
1570 Grant Street
Denver, CO 80203-1714

Ask the agent for the warrant number for your reference. Once the signed affidavit is returned, the accounting team will cancel the lost check and reissue in the Colorado interChange system.

Claim Forms and Attachments

Women's Health

Critical Incident Reporting System Forms

The following forms are for HCBS Service Providers 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, and Community Mental Health Supports,and need to report the critical incident to the SEP Agency Case Manager.

Dental Forms
  • Dental Certification - Effective October 1, 2005, this document must be completed and attached to all dental claims submitted on paper to the Department's Fiscal Agent.
  • For all other forms related to dental: DentaQuest Colorado Medicaid Dental Program Provider ORM (07/14). (This above link will redirect to the DentaQuest Colorado Providers page. Please scroll down to the DentaQuest Resources section to find the link to the current ORM).
Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Forms

Print the relevant questionnaire from the list below and enter all requested information. All questions must be answered in order to make a Prior Authorization Request (PAR) determination. Unless another address is specified on the form, mail the completed form and the completed PAR to:

ColoradoPAR Provider Line

ColoradoPAR Customer Service

ColoradoPAR Provider Fax

Visit the ColoradoPAR: Health First Colorado Prior Authorization Request Program web page or the For Our Providers web page for additional information and ongoing updates.

Federally Qualified Health Center Forms
Visit the Federally Qualified Health Center Forms web page for related forms.
Fingerprinting
Fingerprint Criminal Background Check Other State/Medicare Information Form - Complete this form if fingerprints have been submitted and approved by Medicare or another State Medicaid Agency.
Home Health Forms
Long-Term Services and Supports Case Management Tools

Visit the Long-Term Services and Supports Case Management Tools web page for related forms.

Pharmacy

Visit the Pharmacy Resources web page for related documents and forms.

Post-Eligibility Treatment of Income Forms (PETI)
Physician-Administered Drugs Forms

Visit the Physician-administered Drugs web page for related forms.

Prior Authorization Request (PAR) Forms

Medical PARs are submitted via the Kepro Portal (Atrezzo). This includes PARs for supply, surgery, out of state, therapy, audiology, home health and pediatric behavioral therapy.

Visit the ColoradoPAR: Health First Colorado Prior Authorization Request Program web page or call 1-720-689-6340 for further information. Medical PARs are not submitted through the Provider Web Portal.

Home and Community Based Services (HCBS) waiver PARs are submitted by Case Managers via the Bridge.

If a PAR status shows as pending state review, providers are advised to contact the Provider Services Call Center to ensure the PAR was submitted via the correct method.

Provider Enrollment & Update Forms

Visit the Provider Enrollment web page for more provider enrollment instructions and information.

Rural Health Clinics
Visit the Rural Health Center Forms web page for related forms.
Sterilization Consent Forms
Synagis® Prior Authorization Request Form
Transitions Services Forms

Transition Documents

Information & Reporting Forms

Housing Forms

The Department of Health Care Policy & Financing (the Department) has the ability to verify the social security number of clients who are submitting a HUD application, but do not have a social security card.  Refer to the DAL SSN verification form and the SSN verification form to learn about the process.

The Department works in partnership with the State of Colorado Division of Housing to administer housing vouchers for individuals transitioning from a long-term care facility.

Visit the Division of Housing web page for more information including application forms, guidance and training. Contact Kimberley Dickey at 303-864-7831 or Kimberley.Dickey@state.co.us for more information.

Visit the Transition Services web page for more information.