"Request to Submit Paper Claims Form" - Colorado

Request to Submit Paper Claims Form is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

  • Released on August 1, 2018;
  • The latest edition currently provided by the Colorado Department of Health Care Policy and Financing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Health Care Policy and Financing.

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DXC Technology
P.O. Box 30
Denver, CO 80201
Provider Call Center: 1-844-235-2387
Request to Submit Paper Claims
Please complete this form to request paper claim submission.
Provider Request
Provider ID Number:
Provider Name (Business or Individual):
Location Address:
Address Line 2:
City:
State:
Zip Code:
I attest that the provider will submit 5 or less claims per month.
Provider/Provider Representative Name (please print):
Provider/Provider Representative Signature:
Date:
Contact Information: Phone:
Email:
Please complete this form and mail it to:
DXC, Attn: Provider Enrollment
P.O. Box 30
Denver, CO 80201
For questions regarding Health First Colorado enrollment, please call DXC at 1-844-235-2387.
Revised: August 2018
DXC Technology
P.O. Box 30
Denver, CO 80201
Provider Call Center: 1-844-235-2387
Request to Submit Paper Claims
Please complete this form to request paper claim submission.
Provider Request
Provider ID Number:
Provider Name (Business or Individual):
Location Address:
Address Line 2:
City:
State:
Zip Code:
I attest that the provider will submit 5 or less claims per month.
Provider/Provider Representative Name (please print):
Provider/Provider Representative Signature:
Date:
Contact Information: Phone:
Email:
Please complete this form and mail it to:
DXC, Attn: Provider Enrollment
P.O. Box 30
Denver, CO 80201
For questions regarding Health First Colorado enrollment, please call DXC at 1-844-235-2387.
Revised: August 2018