Health First Colorado - Maternity Bundled Payment Program Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Dear Provider,

Welcome to the Maternity Bundled Payment Program Program Application Form.

Please complete this short form to start the engagement process to learn more about the Maternity Bundled Payment Program. Once the form is submitted, the Department will contact you and verify the information you provided. We will provide the preliminary episode cost thresholds within 14 business days. The Department will then arrange a meeting with your practice for a collaborative review of the data and to answer questions you might have. Once the cost thresholds as well as other program details and requirements are reviewed and accepted by your practice, you will be asked to sign a electronic business agreement (BA) to confirm your participation.

If you have any questions before, during, or after the application, please feel free to contact Steve Harrington at steve.harrington@state.co.us

Thank you for your interest in the Maternity Bundled Payment Program. We appreciate your services to our members.

Practice Name *

Practice Medicaid ID (please list all the Medicaid IDs separated by comma if you have more than one) *

Practice Tax ID *

(Optional) Please briefly describe the reasons for wanting to participate in the program.

Please provide a contact person's full name with email address for follow-up communication with the Department. *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of State.co.us Executive Branch. Report Abuse

Forms