CATCH Patient Eligibility Form

  • Date Format: MM slash DD slash YYYY
  • Home, Work, or Cell
  • Please indicate if monthly or annual income
  • Is the patient covered by any of these programs? Check all that apply.
  • Safety Net Clinic has called to verify current Medicaid status (CCHA Member & Provider Support at 719-598-1540) on date:
    Date Format: MM slash DD slash YYYY

  • Clinician Signature Below

CHP exists to improve the health of the Pikes Peak region. By 2028, CHP will pioneer a process of collaborative leadership that results in measurable improvement in health outcomes. Download more information here.

Sign up for our newsletter
follow us
COntact us
121 South Tejon Street, Suite 601
Colorado Springs, CO 80903
Local: (719) 632-5094
Email: info@ppchp.org

Crafted by Design Rangers at 38.8321° N, 104.8233° W

Scroll to Top