Children applying for Colorado's Children with Life Limiting Illness (CLLI) waiver must have a life-limiting illness attested by a physician, and this one-page statement is that attestation. The treating physician answers whether they are the child's primary care or specialist physician and whether the child has a life-limiting illness, then names the illness with its diagnosis code and signs.
The child's treating physician completes the statement and signs, adding name, specialty practice area and contact details. The client's legal name, date of birth and Medicaid ID go at the top.
Download the current version from the source each time; forms change without notice.
Physician Statement of Life-Limiting Illness
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The client's treating physician, who may be the primary care physician or a specialist; the form asks which. The physician checks one box per question, names the life-limiting illness and its diagnosis code, and signs and dates with specialty practice area and contact details.
A medical condition that, in the opinion of the medical specialist involved, has a prognosis of death that is highly probable before the client reaches adulthood, age 19, without regard to whether curative treatment is present or available.
No. The form tells physicians that enrollment onto the CLLI waiver does not prohibit the use or pursuit of curative treatment. HCPF also states that it holds no physician liable if a client with a life-limiting illness lives to adulthood.