Denver HCP Referral Form

Thank you for the referral to Denver County HCP A Program for Children and Youth with Special Health Care Needs. Please fill out the form below with the identified information. Once you've completed all fields, click on the "submit" button at the bottom of the page. A Denver HCP team member will contact you, via the email listed in the form, with referral determination. Thank you.


For additional local public health agency contact info: www.hcpcolorado.org


Denver HCP:

Ph: 303-602-6765

Fax: 303-436-4798

Lara Anderson, LCSW, Program Manager

SECTION 1: SOURCE INFORMATION

Please fill out your contact information below.

Enter your name and title.

Please enter your organization. If your organization is not listed, you can enter a value instead.

Select or enter value
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Referral Source: Internal vs External

Are you internal or external to Denver Health? If internal, please consider submitting your referral via Epic.

Referral Method*

How are you submitting this referral?

The email address listed will be how a Denver HCP team member will contact you with referral status and updates.

Does the client need information and resources only? Click the box for "yes" and leave blank for "no".

Does the client need care coordination services? Click the box for "yes" and leave blank for "no".

SECTION 2: CLIENT INFORMATION

Please enter the client's information below.

If applicable for internal Denver Health referrals. Leave blank for external referral or if unknown.

Gender*

Please select from the drop-down menu below. If a value is not listed, you may enter it instead.

Select or enter value
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Please select from the drop-down menu below. If a value is not listed, you may enter it instead.

Select or enter value
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SECTION 3: CLIENT'S PHYSICIAN INFORMATION

Please enter the client's Primary Care Physician (PCP) information below. If there is no PCP, you may leave the fields blank.

Please select from the drop-down menu below. If a value is not listed, you may enter it instead.

Select or enter value
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SECTION 4: FAMILY MEMBER/GUARDIAN HOUSEHOLD INFORMATION

Please enter the client's family member/guardian household information below.

If you select "Other", please include the relationship in the "Reason for Referral" field in Section 1 above.

Please select from the drop-down menu below. If a value is not listed, you may enter it instead.

Select or enter value
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Check box for "yes", leave blank for "no".

What is the primary address where the family is residing?

Phone Type (Preferred)*
Alternate Phone Number (Type)

If applicable.

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