CCN referral
Send through your usual secure channel (fax, portal or encrypted email). Never by ordinary email. Reply expected within seven days of the visit, on the CCN consult reply.
| To | Clinician, practice, secure fax or address | ||
|---|---|---|---|
| From | Referring clinician and credentials, practice, phone, secure fax or address, NPI (optional) | ||
| Date | Patient | Name, date of birth, phone | |
| The question | One sentence. | ||
| Why now | What changed, or what made you refer. | ||
| What has been done | Key history and results. Attached: ☐ labs ☐ imaging ☐ genetic testing ☐ prior consult notes | ||
| What I need back | ☐ an answer to the question ☐ a test or procedure ☐ shared care (say what) ☐ you take over this problem | ||
| Urgency | ☐ routine, within 4 weeks ☐ soon, within 1 week ☐ urgent, please call me | ||
| Cash price | ☐ the patient knows your price ☐ price not yet known | ||
| Reply to | Method and secure address | ||
| Signature | |||
Colorado Care Network referral standard: coloradocarenetwork.com/referrals
Colorado Care Network. CCN referral. Version 2026-10-30.