Colorado HIBI Program Online Application Fill out this form. Then click SEND to apply. If you prefer you can Download a Colorado HIBI Program Application to fax or mail to us.

Apply Now

*Required fields.

Step 1. How did you hear about CO HIBI?*Please SelectProgram information mailed to my homeMy Medicaid caseworker gave me program informationA search engine helped me find online information about the programI found program information while on a social network or blogI read about the program in a Medicaid newsletter or publicationA health related support group gave me program informationMy doctor's office gave me program informationMy employer or human resources gave me program informationMy child's school gave me program informationAn employee benefits fair gave me program informationI saw an outdoor program advertisementA friend told me about the program

Step 2. Tell us about the person in your family who is able to receive commercial health insurance at work through an individual commercial health insurance plan, or choose to continue coverage through COBRA.

First name:

*

MI:

Last name:

*

Suffix:

Please SelectJrSrIIIIIIVVVIVIIVIIIIX

Social Security number:

*

Date of birth:

*

"MM/DD/YYYY"

Address:

*

Apartment/Lot #:

City:

*

State

*Please SelectALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAGUAMHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

Zip:

* -

Best phone number to call:

*

Email

Step 3. Tell us about the commercial health insurance or COBRA benefits the person in Step 2 is able to receive. COBRA continuation coverage is a temporary continuation of your group health insurance coverage.

Health insurance company name:

Insurance company address:

City:

State

Please SelectALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAGUAMHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

Zip:

-

Health plan name:

Policy ID number

Group number:

Policy start date:

"MM/DD/YYYY"

Monthly insurance premium

Is this COBRA insurance?

Yes No      COBRA Start Date: * COBRA End Date:

Check the box next to the items your insurance covers:

Doctor VisitsMedicineHospital StaysLab and X-RayOutpatient Hospital

Step 4. Tell us about the employer that offers the health insurance or COBRA.

Employer or company name:

Address:

City:

State

Please SelectALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAGUAMHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

Zip:

-

Phone:

Step 5. Tell us about the family member(s) who are on Medicaid.

First name:

*

MI:

Last name:

*

Suffix:

Please SelectJrSrIIIIIIVVVIVIIVIIIIX

Medicaid ID:

Social Security number:

*

Date of birth:

*

"MM/DD/YYYY"

Is this person pregnant?

Yes No      Due Date: *

Click here to add another family member

Below are the family members you have already added

	First Name	MI	Last Name	SSN	Medicaid ID	DOB	Due Date	Suffix

Enter the characters shown below into the box provided before clicking Submit.

If you would prefer to receive your payment by direct deposit, please download our CO HIBI Direct Deposit FORM and return it to us within 10 days of your application submission.

Please call us at 855-MyCOHIBI or (855)692-6442 or send email to MyCOHIBICustomerService@GainwellTechnologies.com if you experience problems with this form.

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