CCHA RAE 3 Advisory Committee Interested Party Survey

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* 1. Name

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* 2. Email

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* 3. Organization Name (if you are a Health First Colorado Medicaid member, please type in Member)

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* 4. Which Program Improvement Advisory Committee are you interested in?

Program Improvement Advisory Committee (PIAC) - Northern Counties
(Boulder, Broomfield, Clear Creek, Gilpin, Jefferson)

Program Improvement Advisory Committee (PIAC) - Southern Counties
(El Paso, Park, Teller)

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* 5. Are you interested in participating in CCHA's Regional Health Equity Committee?

Yes

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* 6. Sector Represented

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)

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* 7. What population do you represent?

Black Indigenous People of Color (BIPOC)

Members with Disabilities

Members Living in Rural Areas

Child and Youth

LGBTQIA+

All Populations

Other (please specify)

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* 8. Are you interested in collaborating with healthcare providers, other community-based organizations, and Medicaid members to shape regional and state-level initiatives?

Yes

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* 9. What challenges to the communities you serve/live in do you face in accessing and utilizing Medicaid benefits? (Check all that apply)

Transportation

Housing

Access to Care/Services

Language

Food Security

Transitions of Care

Other (please specify)

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* 10. On average, what percentage of individuals that you serve are on Medicaid or potentially eligible but not enrolled?

50%

100%

Clear

i We adjusted the number you entered based on the slider’s scale.