CATCH Patient Eligibility Form

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2019 Annual Report

Focus Areas
- Mega Menu
  HOMELESSNESS
  CHP provides planning, administrative, and data services for the Pikes Peak Continuum of Care to build an effective system of care for people experiencing homelessness.
  About the PPCoC
  HUD CoC NOFA
  PPCoC Resources and Reports
  Homeless Management Information System
  Coordinated Entry
  Access to care
  CHP supports a network of safety net clinics to offer donated medical services to low-income, uninsured people and provides patient navigation services and training to safety net providers.
  Substance Use
  CHP provides support for a coalition of stakeholders engaged in community-centered planning to address the opioid epidemic and other substance use issues.
  Suicide Prevention
  CHP serves as the backbone organization for a county-wide collaborative aimed at reducing suicides by 20% by the year 2024.
Events
About CHP
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Safety Net Clinic*
Client's Name*
First Last
Client's Phone Number*
Client's Address*
Street Address City ZIP / Postal Code
Family size*
Income before taxes (dollar amount)*
Please indicate if monthly or annual income
Insurance Status*
Is the patient covered by any of these programs? Check all that apply.
- Medicaid
- Medicare
- Private Insurance
- Workplace-sponsored insurance
- CICP
- Other
- None
Medicaid Status*
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
Medicaid*
- Yes
- Denied
- Patient is determined to be unable to apply for Medicaid (undocumented, etc.)
- Patient does not meet income guidelines for Medicaid
Clinician Signature Below
Clinic Staff Signature*
Prefix First Last
Signing Consent*
By checking, this Form may be executed and delivered by electronic means and upon such delivery the electronic signature will be deemed to have the same effect as if the original signature had been delivered to the other party.
Date of referral*

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.

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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

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CATCH Patient Eligibility Form

Clinician Signature Below

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