Fillable County Department Fax Information: https://www.colorado.gov/pacific/cdhs/contact-your-county

Fill Online, Printable, Fillable, Blank County Department Fax Information: https://www.colorado.gov/pacific/cdhs/contact-your-county Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

County Department Fax Information: https://www.colorado.gov/pacific/cdhs/contact-your-county

On average this form takes 8 minutes to complete

The County Department Fax Information: https://www.colorado.gov/pacific/cdhs/contact-your-county form is 2 pages long and contains:

  • 0 signatures
  • 25 check-boxes
  • 22 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
County Department Fax Information: https://www.colorado.gov/pacific/cdhs/contact-your-county
Med-9 Instructions for the Client
Important Information
What We Are Asking You To Do?
You need a medical examination to
determine your ongoing eligibility for Aid to
the Needy Disabled (AND).
You need to get the attached Med-9 form
completed by a medical provider* and then
return it to your county office no later
than the redetermination due date.
1. Make an appointment with a medical provider*
2. Ask the medical provider* to:
a. Read the instructions below; and
b. Complete all of gray sections on the Med-9
form
3. Return the completed Med-9 form to your county
office by the due date. You can do this in person,
through email, by fax, by mail or online through
your PEAK account.
Med-9 Instructions for the Medical Provider* (Please Read)
Important Information
What We Are Asking The Medical Provider To Do?
This client has applied for Aid to the Needy
Disabled (AND). AND provides a monthly
payment to individuals that cannot maintain
gainful employment due to a disability.
In order to qualify, a medical provider* must
certify the applicant’s disability by filling out
the attached Med-9 form based on an
assessment of the applicant’s medical
condition.
The words “total disability” on the Med-9
form are derived from regulations. They are
not intended to reflect medical prognosis
terminology.
The county Human Services office and
CDHS will consider your medical opinion
expressed on the form.
1. Evaluate the client’s disability
2. Complete all of the gray Sections on the Med-9
form
a. Check only one disability level box
b. Your signature, provider type, name, address,
phone number, license number, the state
issuing your license and date of exam
3. Return the completed form to the client and you
may send a copy to the county department to assist
the process. You can obtain the county’s fax
number by visiting:
https://www.colorado.gov/pacific/cdhs/contact-
your-county
a. The client’s county of residence is located on
the Med-9 form
b. On the website above, select the
corresponding county to locate the county fax
number
*Acceptable Medical Providers are: Colorado licensed physician (general practitioner or specialist), licensed
psychologist, physician's assistant, advanced practice nurse, registered nurse, licensed professional counselor, or
licensed clinical social worker. Medical certification for blindness shall be completed only by an ophthalmologist
licensed in Colorado.
Colorado Department of Human Services Med-9
The Aid to the Needy Disabled (AND) Program provides financial benefits to Colorado residents who are
disabled. This form is used by County Departments of Human Services to determine medical eligibility for the
AND Program.
Name
SSN
DOB
Address
Phone
Zip Code
City
County
Effective Date
The rest of this form must be completed by one of the following medical professionals licensed in Colorado.
Please select the option that corresponds to your license/certification:
o Physician*
o Licensed Psychologist*
o Registered Nurse*
o Licensed Professional Counselor*
Medical Professional Signature
Printed Name
License Number
State
Date of Exam
Provider Address
Provider Phone
Please select the individual’s diagnosis(es):
o Respiratory disorders
o Cardiovascular disorders
o Digestive disorders
o Genitourinary disorders
o Hematological disorders
o Congenital disorders
o Neurological disorders
o Cancer
o Alcohol/Controlled
Substance Addiction
o Immune System disorders
o Vision, Hearing, or Speech
disorders
o Musculoskeletal disorders
o Mental or Cognitive
disorders
o Other (please define):
Use this space to write any specific
diagnoses or relevant factors to the disorder
type/diagnoses selected on the left:
Select only one of the two disability level options below:
o
This individual has a physical or mental disability/diagnosis(es) listed above which in combination with
other factors, such as age, training, experience, and social setting substantially precludes the individual from
having any employment that exists in the community for which they have competence. This disability is
expected to last 6 months or longer.
This condition is expected to last ____ months. (Please enter a number between 6 and 12.)
o
This individual does not have a physical or mental disability/diagnosis(es) that will last 6 months or longer
and/or does not have accompanied social factors that preclude the individual from having employment in the
community for which they have competence.
Please identify the social factors preventing the individual from employment:
o Age
o Training
o Experience
o Social Setting
Other/Additional:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

County Department Fax Information: https:www.colorado.govpacificcdhscontact-your-county

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 March 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document