Medicaid D-SNP Eligibility Tool Request Form

By providing the required information and my signature below, I certify my understanding that I will be granted access to the State of Colorado Healthcare Policy and Finance (HCPF) Medicaid Portal. With that access, I attest that I will only utilize the portal to verify Medicaid eligibility for prospective/current members for the Denver Health Medical Plan, Inc. Any misuse of the portal may result in revocation of access.

Name (Last, First, Middle Initial)*

Last 4 Digits of Driver License or State ID*

Date of Birth*

NPN*

Telephone #*

Email*

Signature

Date

*Field is required

Medicaid D-SNP Eligibility Tool Request Form

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