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Colorado ULTC 100.2 Professional Medical Info Page

Colorado sends this page to a client's medical provider during a functional needs assessment for long-term care services. A licensed medical professional certifies the client's medical necessity, which the assessment uses to decide whether the client meets nursing facility, ICF/IID or hospital level of care. The page lists diagnoses with ICD codes, current medications, mental health and brain injury diagnoses, and comments.

Who completes it

A licensed medical professional signs to verify the information; another person may complete the entries, giving their name, title and date. The facility or case management agency fills in its own block with the administrator or case manager's name and signature.

Submitting and payment

How to submit it
Return the signed page to the case management agency or facility conducting the functional needs assessment.

Good to know

  • The medical section lists each diagnosis with ICD code and description, and each current medication with name, dosage and frequency.
  • A dementia diagnosis must be validated by a neurological exam documented by the attending physician, and the form asks for the exam date.
  • Separate yes or no questions ask whether the client has a mental health diagnosis and whether there is a traumatic brain injury diagnosis.
  • It is a Word document with form fields, footer ULTC 100.2 10/2015, opening with Dear Medical Provider, so it can be typed before printing and signing.

Get the official form

Download the current version from the source each time; forms change without notice.

Professional Medical Information Page (PMIP)

Official pageWord file

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How this list is checked

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.

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Frequently asked questions

Who can sign Colorado's ULTC 100.2?

A licensed medical professional signs the line verifying the information. The form lets another person complete the entries, recording their name, title and date completed, but the licensed professional's signature is what certifies the client's medical necessity for long-term care services.

What is the ULTC 100.2 used for in Colorado?

It is part of the functional needs assessment that decides whether a client meets nursing facility, ICF/IID or hospital level of care for long-term care services. The case manager or facility conducts the assessment and adds the provider's certification of medical necessity to it.

Does a dementia diagnosis need extra documentation on the ULTC 100.2?

Yes. The form states that a diagnosis of dementia must be validated by a neurological exam with documentation by the attending physician, and it has a field for the neurological exam date next to the diagnosis and medication lists.