CICP Application

Colorado Indigent Care Program

You can download the CICP (Colorado Indigent Care Program) Application below:

Download the CICP Application

Download the CICP Ability to Pay Scale

Requirements for Colorado Indigent Care Program

To schedule a CICP rating interview with our Financial Assistance Counselor call 719-657-4063. You must bring the following information with you at the time of your interview

Residency, Identification, and Citizenship:

• State of Colorado Driver’s License or Colorado Picture I.D., Military I.D. for all household member’s 18 years and older
• Furnish a Social Security Number
• Proof of Citizenship

Gross Earned Income for Household:

• Most recent paystubs for self and spouse
• Most recent Profit/Loss ledger or Business Bank Statements for self-employment

Unearned Income:

• Social Security or Disability Award Letter (SSDI), unemployment award letter, rental income, Workman’s Compensation, spousal maintenance, pensions, settlements, scholarships, bonuses (note: include spouse’s income as well)
• Provide written proof of all other income not listed

Other Verification:

• All medical/pharmacy/dental receipts or statements
• Copy of Health Insurance card
• Proof of payment on health insurance premiums
• Current statement for all checking and savings accounts
• Registration or titles for all vehicles and proof of loan balance if applicable
• Verification of all CD’s, Annuities, Stocks, and Bonds
• Verification of paid child support and childcare

To schedule an appointment call our Financial Assistance Counselor at 719-657-4063
310 County Rd. 14 Del Norte, Co 81132