Health Facilities Information Update
Contact Information
First Name
Last Name
Email
.Facility ID
If you are a CDPHE Facility you can look up your FACID
HERE
If Facility ID is unknown please enter TBD
Street Address of Facility
City of Facility
Zip Code of Facility
Did you receive an invoice?
Yes, I received an invoice
No, I did not receive an invoice
Invoice Number
Invoice number will be in this format: 25-123456
Facility Information
Facility ID
Look up your FACID
HERE
Is this an Off Campus Location (OCL)
?
Yes
No
Is this a Community Mental Health Care Center (CMHC)
?
Yes
No
Street Address of Facility
City of Facility
Zip Code of Facility
Facility Information that needs updated (please choose all that apply)
Facility is closed
Facility was sold
Facility is at a different location/address is incorrect
This facility is not/has never been owned by us and this was received in error
Contact information for this facility is incorrect
Date Closed
If exact date is unknown an approximate date is acceptable.
Date Sold
If exact date is unknown an approximate date is acceptable.
Contact Information
New Contact Email Address
First Name of Contact
Last Name of Contact
Facility Location Information
Date Facility Moved
If exact date is unknown an approximate date is acceptable. If you believe the original address of the facility is incorrect please email cdps_dfpc_coc@state.co.us prior to completing form.
Street Address of Facility
City of Facility
Zip Code of Facility
Contact Information
Previous Contact Email Address
Previous Contact Email Address
New Contact Email Address
New Contact Email Address
First Name of Contact
Last Name of Contact
Contact Information