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Forms & Documents

Find the most recent forms below. If you can't find a form, or need help, please call us.

General Forms

Substance Use Disorder – Provider Application Form
Behavioral Health Prior Authorization Request
Physical Health Prior Authorization Request
Short-Term Behavioral Health Services in a Primary Care Setting
Grievance Form
Quality of Care Notification Form
Essential Community Providers
Care Management Referral Form
Clinical Staff Update Form
Enrollment Backdate Form
Provider Notification of Change Form
Provider Notification of Termination Form
Online Eligibility Verification for off-hours/weekends
Truven/DAP Access Request Form
Authorization to Disclose Protected Health Information
Autorización Para La Divulgación De La Información De Salud Protegida
Request for Access to PHI Form
SOLICITUD DE ACCESO A INFORMACIÓN DE SALUD PROTEGIDA

CHP+ offered by Colorado Access

Retro-Eligibility Claims Guidelines

Claims

General Companion Guide – Healthcare Claim Submissions
Claim Appeal Form
Provider Payment Options

Utilization Management and Pharmacy

Prior Authorization Durable Medical Equipment Request
Master Authorization List (Please use FireFox, Edge or Safari to download)
Clinical Appeal Form
Prior Authorization for Home Health Care/Outpatient Therapy (may be used for Synagis at-home administration)
Prior Authorization Injectable Medication
Psychological Testing Authorization
Compounded Medication Claim Form
Intensive In-Home Services Application
Navitus Announcement
Navitus Synagis
SUD Prior Authorization Request
SUD 3.7WM Authorization Request
SUD Quality Measures Guidance for Providers

Provider Frequently Asked Questions

How do I get Synagis for my patients?

Complete prior authorization forms and fax them to Navitus at 855-668-8551. All approved Synagis requests will be dispensed by Avella Specialty Pharmacy. If you wish to have a home health agency administer Synagis to your patient, please indicate that the medication will be shipped to the patient’s home. Upon prior authorization approval, Navitus will notify Avella, who will fax a home health request to set up the services. Our utilization management team will work to set up a home health agency to visit the patient’s home and administer the medication.

Is Synagis covered by Colorado Access?

Synagis is covered for eligible patients through the Colorado Access pharmacy benefit. The specific criteria for approval can be found here. Prior authorization forms should be faxed to Navitus at 855-668-8551.