Medicare Appointment of Representative Form

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Please return this completed form and all supporting documentation to the following mailing address or fax number

MAIL
Denver Health Medical Plan, Inc.
Attn: Health Plan Services
777 Bannock St. MC6000
Denver, CO 80204

FAX
303-602-2138

PDF Download

Medicare Appointment of Representative Form - English112.73 KBMedicare Appointment of Representative Form - Spanish86.66 KBMedicare Appointment of Representative Form - English Large Print77.17 KBMedicare Appointment of Representative Form - Spanish Large Print223.68 KB

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