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?*
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:
  
Social Security number:
*
Date of birth:
*
"MM/DD/YYYY"
Address:
*
Apartment/Lot #:
  
City:
*
State
*
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
  
Zip:
   -
Health plan name:
  
Policy ID number
  
Group number:
  
Policy start date:
  
"MM/DD/YYYY"
Monthly insurance premium
  
  

Is this COBRA insurance?
Yes No

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
  
Zip:
   -
Phone:
  

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

First name:
*
MI:
  
Last name:
*
Suffix:
  
Medicaid ID:
  
Social Security number:
*
Date of birth:
*
"MM/DD/YYYY"

Is this person pregnant?
Yes No


Enter the numbers shown below in to the box provided before clicking Submit.

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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 CustomerService@MyCOHIBI.com if you experience problems with this form.

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