CCHA | Grievance Form

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If you have a problem with your Health First Colorado services or providers, we want you to tell us about it. Please use the form below to submit a complaint or grievance – "any expression of dissatisfaction"

Form User Information

Date Submitted: *

Member Email: *

Member ID: *

Member Name: *

Member Phone: *

If you are not the member, please provide the following information

Your Name:

Your Phone:

Your Email:

Relationship to Member:

Parent
Provider
Member Authorized Representative or Legal Guardian*
Provider on Member’s Behalf
Care Coordinator on Member’s Behalf

*Note: We must have written authorization to allow you to act on the member’s behalf if you aren’t their authorized representative or legal guardian.

Grievance Information

Does this complaint involve: *

Behavioral Health Services
Physical Health Services
Both Behavioral Health and Physical Health Services
Not Applicable

Summary of the Complaint: *

Please provide a summary of your complaint. Include, if available, the following information: Name of the provider who will or has provided care; Contact information of the provider; The date(s) of service; Service amount(s) if complaint is related to billing; Who the bill is for and their Medicaid ID, if not member the claim or reference number for the specific decision that you don’t agree with; and the specific reason(s) why you don’t agree with the decision.

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.