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

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