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

 

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.