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Provider Forms and References

See the items below to stay up-to-date with forms, reference guides, and other items that are important to your practice.

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Provider Forms

Rocky Mountain Health Plans has a variety of forms specific to Colorado Medicaid. Health care professionals transitioning to UnitedHealthcare can use the following forms when providing services:

Colorado Medicaid sterilization consent form (med-178)
Out of Network Request form
Patient Choice form instructions
Patient Choice form (print version)
Patient Choice form (digital version)
Patient Choice form - Spanish
Provider referral form
Release of Information form
Release of Information form - Spanish
Synagis Enrollment form

To access behavioral health service forms, click here.

Colorado Department of Health Care Policy and Financing

To learn more about Medicaid in Colorado visit the Colorado Department of Health Care Policy and Financing.

Reference Guides

Coordinating Care as the single-entry point (SEP)
Rocky Mountain Health Plans is the SEP agency in Mesa County, Costilla County, Conejos County, Mineral County and Rio Grande County.

The SEP determines member eligibility for long-term care services, like home and community-based services, long-term home health, nursing home care, and home care allowance. The SEP point of contact between programs and members in need of this care. Review the Coordinating Care as the Single Point of Entry for more information.

Submit a Pre-Service Appeal and or Grievance for a Medicaid Member

Medicaid Pre-Service Appeal or Grievance