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

Transitioning From



Transitioning From - Member's Care Team
Member Information


(Parent/guardian or other family member/caretaker)







Alternate Contact (Parent/guardian or other family member/caretaker)


Include signed Release of Information with this form.

i.e. ROI, guardianship paperwork, etc.

Care Coordination Information





















PLEASE DESCRIBE THE SPECIFIC REASON FOR REFERRAL, PROVIDE RELEVANT BACKGROUND INFORMATION, OUTLINE ACTIONS TAKEN BY THE RAE TO DATE, AND SPECIFY ANY OUTSTANDING NEEDS OR NEXT STEPS.




















CHECK ALL THAT APPLY AND ELABORATE FOR ANY BOX CHECKED.

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.