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CCHA RAE 3 Advisory Committee Interested Party Survey
*
1.
Name
(Required.)
*
2.
Email
(Required.)
*
3.
Organization Name (if you are a Health First Colorado Medicaid member, please type in Member)
(Required.)
*
4.
Which Program Improvement Advisory Committee are you interested in?
(Required.)
Program Improvement Advisory Committee (PIAC) - Northern Counties
(Boulder, Broomfield, Clear Creek, Gilpin, Jefferson)
Program Improvement Advisory Committee (PIAC) - Southern Counties
(El Paso, Park, Teller)
5.
Are you interested in participating in CCHA's Regional Health Equity Committee?
Yes
No
*
6.
Sector Represented
(Required.)
Health First Colorado Member
Members' Families and/or Caregiver
Primary Care Medical Provider (PCMP)
Behavioral Health Provider
Specialist Provider
Hospital
Long-Term Services & Supports
Nursing Facility
Oral Health
Advocacy Organization
Community-Based Organization
Local Public Health
Child Welfare Interests
Aging/Elderly/DSNP
Other (please specify)
*
7.
What population do you represent?
(Required.)
Black Indigenous People of Color (BIPOC)
Members with Disabilities
Members Living in Rural Areas
Child and Youth
LGBTQIA+
All Populations
Other (please specify)
*
8.
Are you interested in collaborating with healthcare providers, other community-based organizations, and Medicaid members to shape regional and state-level initiatives?
(Required.)
Yes
No
*
9.
What challenges to the communities you serve/live in do you face in accessing and utilizing Medicaid benefits? (Check all that apply)
(Required.)
Transportation
Housing
Access to Care/Services
Language
Food Security
Transitions of Care
Other (please specify)
*
10.
On average, what percentage of individuals that you serve are on Medicaid or potentially eligible but not enrolled?
(Required.)
0%
50%
100%
Clear
Current Progress,
0 of 10 answered
