SMBHF New Provider Application

    New Provider Application

    This form is for Colorado licensed behavioral health services providers to apply for reimbursement through the San Miguel Behavioral Health Fund. To be added to the Approved Providers List please submit a current Colorado license and W9 form below. Tri-County Health Network will process the application and determine eligibility within 10 working days. Services provided prior to approval will not be reimbursed by the fund. If you have any questions, please contact Tri-County Health Network at

    Provider Information

    Documentation Requirements

    Providers are required to submit an updated W-9 and a current copy their Colorado license before reimbursement can be paid.

    If you have problems uploading your documents via this form, you can email them to instead.

    Electronic Signature Agreement

    I certify, to the best of my knowledge, that all information in this application is true and accurate. I understand that all information is subject to verification and approval by Tri-County Health Network.

    The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

    (Use your mouse or trackpad to sign.)

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