Long-Term Services and Supports Case Management Forms and Tools
CMA Forms CCM Resources CIRS Forms DD Forms NOA Forms Program and Waiver Resources
SIS Resources Other Forms and Resources
Forms and resources used primarily by Case Management Agencies (CMA):
Case Management Agency Forms (Offline)
- Care Plan Form - July 2023
- LTC Assessments for IADLs Form - July 2023
- Service Plan Form - July 2023
- Assessment/Support Plans: LTC Level of Care Eligibility Assessment (Legacy ULTC 100.2) - June 2023
- This form replaces the ULTC 100.2 Initial Screening and Intake Form
- This form replaces the ULTC 100.2 Initial Screening and Intake Form
- Colorado Intake Screen Tool - Updated June 29, 2023
- This form replaces the ULTC 100.2 Initial Screening and Intake Form
- This form replaces the ULTC 100.2 Initial Screening and Intake Form
- Case Management Agency and Eligibility Information Sharing Form - January 2024
- This form replaces the Case Management Agency and Eligibility Information Sharing Form - 2018 and June 2023
- This form replaces the Case Management Agency and Eligibility Information Sharing Form - 2018 and June 2023
- Service Plan Signature Page - Updated January 2025 for Accessibility
- No changes to this form - continue to use this form per regulatory and contractual requirements.
- No changes to this form - continue to use this form per regulatory and contractual requirements.
- Professional Medical Information Page (PMIP)
- No changes to this form - continue to use this form per regulatory and contractual requirements.
Care and Case Management System (CCM) Resources
Critical Incident Report Forms (Offline)
- Critical Incident Form - Criminal Activity - June 2023
- Critical Incident Form - Damage to Consumer's Property or Theft - June 2023
- Critical Incident Form - Death - June 2023
- Critical Incident Form - Injury or Illness to Client - June 2023
- Critical Incident Form - Medication Management - June 2023
- Critical Incident Form - Missing Person - June 2023
- Critical Incident Form - Mistreatment, Abuse, Neglect, Exploitation - June 2023
- Critical Incident Form - Unsafe Housing - June 2023
- Critical Incident Form - Other High-Risk Issues - June 2023
Developmental Disability Determination Forms and Resources
- Developmental Disability Determination Definition Fact Sheet - Updated January 2021
- Spanish version - January 2021
- Spanish version - January 2021
- Developmental Disability and Delay Determinations FAQ - April 2020
- Spanish version - April 2020
- Spanish version - April 2020
- Request for Developmental Disability Determination Form - Updated July 2019
- Spanish Version - May 2019
- Spanish Version - May 2019
- Developmental Disability Determination Decision Form - Updated June 2019
- Spanish Version - April 2019
- Spanish Version - April 2019
- Developmental Delay Determination Decision Form - Updated June 2019
- Spanish Version - April 2019
- Spanish Version - April 2019
- Informational Memo - IM 19-054 - Developmental Disability and Delay Determinations Frequently Asked Questions - September 2019
- Developmental Disability and Delay Determinations FAQ Sheet - September 2019
- Developmental Disability and Delay Determinations FAQ Sheet - September 2019
- Informational Memo - IM 18-49 - The Role of Psychological Testing in Accessing Medicaid Services FAQ - December 2018
Notice of Action (803) Forms
- Long-Term Care Application Status Letter - Updated July 2, 2025 (auto download)
- Long-Term Care Benefits Status Letter - July 1, 2025 (auto download)
- Long-Term Care Developmental Disabilities (DD) Waiver Waitlist Letter - Updated November 26, 2024 (auto download)
- Case Status Advisement Letter - April 2025 (auto download)
- Long-Term Care Notice of Action Withdrawal Letter - Updated July 2025 (auto download)
Program and Waiver-Specific Resources
- CwCHN Attestation Form and Case Manager Decision Tree - July 2025 (auto download)
- Informed Consent for Rights Modification Template - June 2025
- Spanish Version - June 2025
- Spanish Version - June 2025
- Interim CFC Direct Care Services Calculator - Adults - April 29, 2025 (auto download)
- Interim resource for calculating direct care services for Adults under Community First Choice
- Interim CFC Direct Care Services Calculator - Children - April 2025 (auto download)
- Interim resource for calculating direct care services for Children under Community First Choice
- Interim resource for calculating direct care services for Children under Community First Choice
- OBRA Specialized Services Support Plan - Updated April 2025
- Spanish version - April 2025
- CHRP SED Attestation Form - Updated February 2025
- Home and Community-Based Services (HCBS) Settings Final Rule Ongoing Monitoring Guide - December 2024
- Unit Converter for Support Planning - July 2022
- State Supported Living Services (State SLS) Support Plan - March 2020
- Children's Extensive Support (CES) Waiver - Behavioral and Medical Supports Application - February 2020
- Physician Statement of Life-Limiting Illness - Updated September 2020
- Pre-Admission Screening and Resident Review Level I form (PASRR)
- ACF/SLP/TLP PETI Form
- Over-Threshold Respite Request Form - Updated April 2025
Supports Intensity Scale (SIS)
- Risk Factor Training - May 2024
- Support Level Review Request Form - Updated May 2023
- Level 7 Rate Request Form - March 2022
- Desk Guide - August 2022
- Support Level Review Process - August 2021
- Support Level Review Panel Schedule - 2025
- SIS Assessment Report Cover Letter - May 2023
- SIS and Support Level Information and Disclosure - May 2023
- SIS Complaint Process - August 2024
SIS and Support Level Review Technical Assistance Meetings
- May 17, 2023
- August 16, 2022
- March 31, 2022
- SIS Reassessment Request Form - Updated June 2022
- SIS-A Respondent Guide - Updated April 2023 (This document was provided by a third party. People using assistive technology may not be able to fully access the information in this file. For assistance, email Mariah.Kohlruss-Ecker@state.co.us)
- SIS-A Respondent Guide Spanish - Updated April 2023 (This document was provided by a third party. People using assistive technology may not be able to fully access the information in this file. For assistance, email Mariah.Kohlruss-Ecker@state.co.us)
- SIS-A Respondent Resources
SIS-A Scoring Conversion Tables - 2017
- Appendix B-Scoring Conversion Table
- Appendix C-1-Scoring Conversion Table
- Appendix C-2-Scoring Conversion Table
Support Level Subgroup Definitions - June 2017
American Association on Intellectual and Developmental Disabilities (AAIDD) Website
Other Forms and Resources
- Health, Safety, and Welfare Roles and Responsibilities Fact Sheet - July 2025
- LTSS Level of Care Referral Form - Updated May 2025
- Formal Discontinuation Notice for Providers - Updated May 2025 (auto download)
- LTSS Case Management Agency Roles and Responsibilities - November 2024
- LTSS Case Manager Roles and Responsibilities - November 2024
- LTSS Member Preference Guide - August 2024
- Spanish version - August 2024
- Telligen Express Review Qualification Attestation Form - March 2022
- State Supported Living Services (State SLS) Support Plan - March 2020
- LTSS Training - resource for training materials designed for Long-Term Services and Supports Case Managers
- Long-Term Services and Supports Programs Page
- Care and Case Management (CCM) Page
- PASRR - resource for information and forms for Pre-Admission Screening and Resident Review program
- State Long-Term Care Ombudsman Website