Get Medicaid Accountable Care Collaborative Program - Vccc

This guide provides a clear and comprehensive overview of how to complete the Medicaid Accountable Care Collaborative Program - Vccc form online. By choosing a Primary Care Medical Provider through this process, you can ensure that you receive appropriate healthcare services under the program.

Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to download the form and open it for editing.
2. Enter the date in the designated field at the top of the form. This is important for record-keeping.
3. In the first blank, write the name of the Primary Care Medical Provider (PCMP) you have chosen to serve you.
4. Provide the PCMP's phone number in the next field. This ensures that communication can be easily established.
5. If available, optionally include the PCMP's Medicaid Billing number for processing purposes.
6. Fill in your Medicaid ID number, which can be found on your Medicaid ID card. Ensure all seven digits are included.
7. Enter your Social Security Number or Date of Birth in the respective field. This is for identification purposes.
8. Print your full name at the bottom of the form to signify your agreement.
9. Sign the form, confirming that you are the Medicaid member, parent, or legal guardian responsible for the application.
10. Once completed, either fax the form to HealthColorado at 303-832-8352 or mail it to the provided address.

Take action and fill out your form online today!