CCHA | Care Coordination Referral Form

Referring Agency/Practice: *

Person Referring: *

Email: *

Phone: *

Referral Date: *

Member Name: *

Member Phone: *

Member Date of Birth (DOB): *

Health First Colorado ID Number:

Primary Language:

POA, guardianship paperwork, or ROI required to outreach alternate contact for members 18 and older, please include document(s) with referral.

Alternate Contact (Name):

Alternate Contact (Phone):

Alternate Contact (Relationship to Member):

Primary Care Physician (Name):

Primary Care Physician (Phone):

Case Management Agency (Name):

Case Management Agency (Phone):

Behavioral Health Provider (Name):

Behavioral Health Provider (Phone):

Other Provider/Agency (Name):

Other Provider/Agency (Phone):

Who holds custody of the member? (Name):

Who holds custody of the member? (Phone):

Who holds medical decision-making? (Name):

Who holds medical decision-making? (Phone):

Who holds educational decision-making? (Name):

Who holds educational decision-making? (Phone):

DHS Caseworker (Name):

DHS Caseworker (Phone):

Are parental rights intact?:

Yes
No

Should parents be outreached?:

Yes
No

Guardianship Documentation:

To better serve the member, please provide additional details of the needs/concerns:

User Verification: *