Get Co Approved Treatment Provider Program Enrollment Request 2021-2026

This guide provides clear and comprehensive steps for completing the CO Approved Treatment Provider Program Enrollment Request form online. Whether you are a new provider or updating your current information, following these instructions will help streamline the submission process.

Follow the steps to successfully complete the enrollment request form.

1. Click ‘Get Form’ button to access the CO Approved Treatment Provider Program Enrollment Request form and open it for editing.
2. Begin by entering the date in the designated field at the top of the form to indicate when you are submitting your enrollment request.
3. Provide your agency name in the appropriate field to ensure that your submission is accurately identified.
4. Fill in your agency's address, including street address, city, state, and ZIP code, to facilitate communication.
5. Enter the name of the contact person within your agency who will be responsible for this enrollment request.
6. Include the contact person's phone number and email address to ensure you can be reached for any follow-up.
7. Select the type of agency from the provided options, marking the appropriate box for 'Corporation', 'Individual', 'Proprietor', or other.
8. Indicate whether you are an approved Medicaid funded provider by checking the applicable box.
9. List any additional insurance your agency accepts in the specified section.
10. Specify the types of therapy offered by checking the relevant boxes for tele-therapy, in-person services, or both.
11. If applicable, indicate if you have Spanish speaking therapists or offer LGBTQ+ classes, along with any details regarding specific classes and genders served.
12. Submit a copy of your W-9 form to the designated email if you are a new ATP provider.
13. Review the treatment/services section and check all services your agency can provide, ensuring accuracy of the selected services.
14. Complete the list of therapists and polygraph examiners associated with your agency, including their names and license numbers.
15. If applicable, provide information for additional locations and services offered by your agency, ensuring to note any differences in services.
16. Once you have filled out all necessary fields, save your changes, and then download, print, or share the completed form as needed.

Complete your CO Approved Treatment Provider Program Enrollment Request online today.