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Care Coordination Referral Form (Health First Colorado Region 7)

Please use this form when referring Health First Colorado (Colorado’s Medicaid Program) members to CCHA for care coordination services.

CCHA serves members attributed to PCPs located in the following counties: El Paso, Park and Teller.

REFERRING FROM
MEMBER INFORMATION
ALTERNATE CONTACT – Parent/Guardian or Other Family Member/Caretaker (if applicable)


REASON FOR REFERRAL (check all that apply)




















OTHER NOTES/CONCERNS

If you need the information on this page in another format, please contact CCHA Member Support Services.

The information will be provided in paper form free of charge within 5 business days.

We can connect you to language services or help you find a provider with ADA accommodations.

If you are having a medical or mental health emergency, call 911 or go to your nearest hospital-based ER.

If you are having a mental health or substance use crisis, call Colorado Crisis Services at 1-844-493-8255.