If you are a licensed Colorado physician with a written MOU on file with UPRHSD and would like to order a patient visit with the UPRHSD Community Paramedicine Program, please fill out the form below.
NOTES: Your submission of this order form must be followed up by a phone call to the Appointment PSAP Center. This form must be fully completed and submitted for each POP visit desired for every patient. You will have the opportunity to resubmit the form with most patient information retained after each submission. Instructions will be provided after submission.
This form may take several days to be processed and is not designed to manage emergency situations.
All information submitted via this form is encrypted and handled in strict accordance with HIPAA law.
Thank you for your PACT Patient Enrollment Request.
TO SCHEDULE ANOTHER VISIT FOR THIS SAME PATIENT, Please click the SCHEDULE AGAIN button and enter a different date and/or time range and and click SUBMIT again. Repeat for each visit for the same patient.
To schedule a visit for a new patient, please CLICK HERE.
It will take a few business days to complete the enrollment. We will contact you if we find any problems with the information you have submitted, or if there are any other problems with completing this request.
All information submitted via this form is encrypted and handled in strict accordance with HIPAA law.
Best Regards,
Ute Pass Regional Health Service District
