Get Rendering Provider Application - Colorado.gov - Colorado

Completing the Rendering Provider Application is an essential step for individual practitioners seeking to enroll in the Colorado Medical Assistance Program. This guide provides clear instructions to help you navigate the application process effectively.

Follow the steps to complete your application successfully.

1. Press the ‘Get Form’ button to access the application form. This will open the document for you to begin filling it out.
2. Complete the 'Name and Individual Information' section, which requires your full name, social security number, date of birth, and relevant Medicaid participation status.
3. Fill in the 'Address Information' section by providing your service location address, billing office address, and mailing address, including phone numbers for each.
4. In the 'Provider Type, Licensure and Specialty Information' section, identify your provider type and include any required licensure information.
5. Provide details in the 'Insurance and Other Registration Information' section, including your malpractice/general liability insurance information and any other necessary registrations.
6. Complete the 'Provider Disclosures' section, which may require you to disclose ownership, control interests, or any convictions related to the Medicaid programs.
7. In the 'Affiliation and Contact Information' section, list any billing groups or clinics affiliated with you and provide a contact name and number for any inquiries regarding the application.
8. Review and sign the 'Provider Participation Agreement' to affirm your understanding and acceptance of the terms required for participation.
9. After filling out all sections, ensure all information is accurate and complete. You may then save your changes, download the document, print it, or share it as necessary.

Start filling out your Rendering Provider Application online today to ensure your participation in the Colorado Medical Assistance Program.