"Fingerprint Criminal Background Check Other State/Medicare Information Form" - Colorado

Fingerprint Criminal Background Check Other State/Medicare Information 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 May 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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Download "Fingerprint Criminal Background Check Other State/Medicare Information Form" - Colorado

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DXC Technology
P.O. Box 30
Denver, CO 80201
Fingerprint Criminal Background Check Other State/Medicare
Information Form
Complete this form if fingerprints have been submitted and approved by Medicare or
another State Medicaid Agency. Please type or print clearly.
Legal Name of Business(es) or Individual Provider: ______________________________________________________________
Health First Colorado Program Provider ID: ____________________________________________________________________
List all Individual(s) with 5% or more ownership/control interest and last 4 digits of SSN for each (attach a separate page if more
room is needed):
Name
Last Four of SSN
Fingerprints Submitted to
Other State Medicaid
States
Medicare
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Contact Information:
Name: ______________________________ Phone: _____________________
Email: ______________________________________________
Please complete this form and mail it to:
DXC Technology
Attn: Provider Enrollment - Fingerprinting
P.O. Box 30
Denver, CO 80201
Revised: May 2018
Our mission is to improve health care access and outcomes for the people we serve while demonstrating
www.colorado.gov/hcpf
sound stewardship of financial resources.
DXC Technology
P.O. Box 30
Denver, CO 80201
Fingerprint Criminal Background Check Other State/Medicare
Information Form
Complete this form if fingerprints have been submitted and approved by Medicare or
another State Medicaid Agency. Please type or print clearly.
Legal Name of Business(es) or Individual Provider: ______________________________________________________________
Health First Colorado Program Provider ID: ____________________________________________________________________
List all Individual(s) with 5% or more ownership/control interest and last 4 digits of SSN for each (attach a separate page if more
room is needed):
Name
Last Four of SSN
Fingerprints Submitted to
Other State Medicaid
States
Medicare
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Yes ☐ No ☐
Contact Information:
Name: ______________________________ Phone: _____________________
Email: ______________________________________________
Please complete this form and mail it to:
DXC Technology
Attn: Provider Enrollment - Fingerprinting
P.O. Box 30
Denver, CO 80201
Revised: May 2018
Our mission is to improve health care access and outcomes for the people we serve while demonstrating
www.colorado.gov/hcpf
sound stewardship of financial resources.