Contact Denver Health Medical Plan

First Name *

Last Name *

Phone Number *

Email Address *

Member ID (enter N/A if you do not know) *

Date of Birth *

Message *

Current Plan *

ATTACH SUPPORTING DOCUMENTATION:

IMPORTANT: to upload more than one document, select all documents from your computer. On Windows hold ctl-key and click to select more than one file. On Mac, hold apple-key and click to select more than one file.

DOWNLOAD FORM DATA (PRIOR TO SUBMISSION):

If you would like to download the data you have entered in this form, click on the 'Download Form Data' button below. A CSV file that contains the data you are providing in this form will be downloaded to your computer. You need to click the 'Download Form Data' button after you have completed the form but before you click on the 'Submit Form' button.

SUBMIT FORM:

You must complete all required fields prior to submission. To ensure files and data are successfully submitted, do not close this window until you see a 'Thank You' confirmation page.

*Field is required

Contact Denver Health Medical Plan

Contact DHMP

ATTACH SUPPORTING DOCUMENTATION:

DOWNLOAD FORM DATA (PRIOR TO SUBMISSION):

SUBMIT FORM: