"Enrollment Legal Name Change Form" - Colorado

Enrollment Legal Name Change 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 January 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;

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.

ADVERTISEMENT
ADVERTISEMENT

Download "Enrollment Legal Name Change Form" - Colorado

207 times
Rate (4.8 / 5) 10 votes
DXC Technology
P.O. Box 30
Denver, CO 80201
Provider Call Center: 1-844-235-2387
Enrollment Legal Name Change Form
Please complete this form to request a legal name change for an existing provider.
Provider Request
Tax ID Number: ______________________
Please note that the legal name will change for all providers with this Tax ID.
Current Provider Name (Business or Individual):
________________________________________________________________
_____________________________________________________________________________________________________
New Legal Name:_____________________________________________________________________
Location Address:____________________________________________
Address Line 2:____________________________
City:____________________________________
State:____________________________
Zip Code:________________
For an Individual name change, please attach a SSN card, marriage license or legal name change document. The individual
must sign this form.
For a group or facility name change, please attach a 147C from the IRS and a current W9. A representative may sign this
form on behalf of the group.
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 Provider Services at 1-844-235-2387.
Revised: January 2018
Our mission is to improve health care access and outcomes for the people we serve while demonstrating sound
stewardship of financial resources.
www.colorado.gov/hcpf
DXC Technology
P.O. Box 30
Denver, CO 80201
Provider Call Center: 1-844-235-2387
Enrollment Legal Name Change Form
Please complete this form to request a legal name change for an existing provider.
Provider Request
Tax ID Number: ______________________
Please note that the legal name will change for all providers with this Tax ID.
Current Provider Name (Business or Individual):
________________________________________________________________
_____________________________________________________________________________________________________
New Legal Name:_____________________________________________________________________
Location Address:____________________________________________
Address Line 2:____________________________
City:____________________________________
State:____________________________
Zip Code:________________
For an Individual name change, please attach a SSN card, marriage license or legal name change document. The individual
must sign this form.
For a group or facility name change, please attach a 147C from the IRS and a current W9. A representative may sign this
form on behalf of the group.
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 Provider Services at 1-844-235-2387.
Revised: January 2018
Our mission is to improve health care access and outcomes for the people we serve while demonstrating sound
stewardship of financial resources.
www.colorado.gov/hcpf