Medicaid Transition to Community Request Form

Medicaid Transition to Community Request Form
Community options counseling referrals submitted using this form will be sent to agencies contracted with the Colorado Department of Health Care Policy and Financing (HCPF) to conduct options counseling related to transitioning back into the community. Agencies are required to meet with Medicaid Members within 10 business days of receiving a referral. If the Member has not been contacted within 10 business days of this form's submission or if you have any questions or concerns about this referral, please email hcpf_clo_inreach@state.co.us.

Find the local contact in your region

PACE Enrollment
Is the member enrolled in PACE?

YesNoUnsure

PACE Member Next Steps

Members enrolled in PACE, interested in transitioning back to the community from a facility, should contact their PACE provider first to learn about transition services offered through the PACE Program.

PACE Organization	County/Zip Code/Service Area	Phone Number
HopeWest PACE	Mesa: 81501, 81502, 81503, 81504, 81505, 81506, 81507, 81520, 81521, 81524, 81526, 81527	970-255-7223 TTY: 800-659-2656
InnovAge Colorado PACE	Adams: 80002, 80003, 80010, 80011, 80020, 80022, 80030, 80031, 80045, 80212, 80216, 80221, 80229, 80233, 80234, 80241, 80249, 80260, 80601, 80602, 80614, 80640 Arapahoe: 80010, 80011, 80012, 80013, 80014, 80017, 80110, 80113, 80120, 80121, 80122, 80123, 80128, 80222, 80231, 80236, 80247 Broomfield: 80020, 80023 Denver: All zip codes Jefferson: 80002, 80003, 80004, 80005, 80021, 80031,80033, 80123, 80127, 80128, 80212, 80214, 80215, 80226, 80227, 80228, 80232, 80235, 80401, 80403, 80465 Larimer: 80513, 80521, 80523, 80524, 80525, 80526, 80528, 80537, 80538, 80547 Pueblo: 81001, 81003, 81004, 81005, 81006, 81007, 81008 Weld: 80534, 80543, 80550, 80615, 80620, 80631, 80634, 80639	Toll Free: 844-948-0792 TTY: 711
Rocky Mountain PACE	El Paso: 80132, 80133, 80817, 80829, 80903, 80904, 80905, 80906, 80907, 80908, 80909, 80910, 80911, 80914, 80915, 80916, 80917, 80918, 80919, 80920, 80921, 80922, 80923, 80924, 80925, 80927, 80939, 80951	Toll Free: 855-207-0702 TTY: 800-659-2656
Senior CommUnity Care PACE	Delta: 81410, 81413, 81415, 81416, 81418, 81419, 81428 Montrose: 81401, 81402, 81403, 81415, 81416, 81425	Toll Free: 866-961-1451 TTY: 970-435-4018
TRU PACE	Adams: 80030, 80031, 80221, 80640, 80229, 80233, 80234, 80241, 80260, 80601, 80602 Boulder: All zip codes Jefferson: 80002, 80003, 80004, 80005, 80007 Weld (Southwest): 80504, 80514, 80516, 80520, 80530, 80542, 80603, 80621, 80651	Toll Free: 844-350-7223 TTY: 800-659-2656

Would the member like more information or support exploring their transition options?

YesNo
Please select next to fill out the rest of the form and submit a referral to their local options counseling agency who will help them explore their options.

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Medicaid Transition to Community Request Form

PACE Enrollment

PACE Member Next Steps

Member Information

Nursing Facility Information

Referral Information

Form Experience