IHSS Forms

Welcome to Consumer Direct Care Network Colorado’s In-Home Support Services (IHSS) Forms page. These forms are designed to provide members and case managers working with in the Colorado IHSS programs the tools needed to support enrollment and follow-up services.

IHSS Tools and Forms

IHSS Shared Responsibilities Plan

IHSS Shared Responsibilities Plan – October 2022 – PDF

IHSS Shared Responsibilities Plan – October 2022 – Spanish – PDF

IHSS Shared Responsibilities Plan – October 2022 – Vietnamese – PDF

IHSS Care Plan Calculator

IHSS Care Plan Calculator – July 2022 – XLS

IHSS Care Plan Calculator – July 2022 – Spanish – XLS

IHSS Care Plan Mediation Letter

IHSS CM Care Plan Mediation Letter – PDF

IHSS Physician Attestation

IHSS Physician Attestation – English – PDF

IHSS Physician Attestation – Russian – PDF

IHSS Physician Attestation – Spanish – PDF

IHSS Physician Attestation – Vietnamese – PDF

IHSS Referral Form

IHSS Referral Form – English – PDF

IHSS Referral Form – Russian – PDF

IHSS Referral Form – Spanish – PDF

IHSS Referral Form – Vietnamese – PDF

Care Plan Mediation Request Form

Care Plan Mediation Request Form – English – PDF

Care Plan Mediation Request Form – Russian – PDF

Care Plan Mediation Request Form – Spanish – PDF

Care Plan Mediation Request Form – Vietnamese – PDF

Health Maintenance Activities (HMA) Documentation Guide

Health Maintenance Activities (HMA) Documentation Guide – PDF

Telligen Provider User Guide

Telligen Provider User Guide – PDF