CCHA | Care Coordination Referral Form

Referring From

Provider Type: *

Primary Care Physician
Behavioral Health Provider
Case Management Agency
Other Provider

Referral Date: *

Member's Care Team

Member Information

Health First Colorado ID Number:

Member Name: *

Member Date of Birth (DOB): *

Member Phone: *

Primary Language: *

Is there a primary contact for this referral?: *

Yes
No

Does the member have an alternative contact?: *

Yes
No

(Parent/guardian or other family member/caretaker)

Is Department of Human Services (DHS) – Child & Youth Involved?: *

Yes
No

Primary Contact

Primary Contact (Name): *

Primary Contact (Phone): *

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

Alternate Contact (Name): *

Alternate Contact (Phone): *

Alternate Contact (Relationship to Member): *

Member has consented to contact and exchange information with this person?: *

Yes
No

If Department of Human Services (DHS) is Involved (Please attach any guardianship documentation)

DHS Caseworker (Name): *

DHS Caseworker (Phone): *

DHS Caseworker (Email): *

Are parental rights intact?: *

Yes
No

Should parents be outreached?: *

Yes
No

Guardianship Documentation: