CICP Application2018-04-26T13:04:59+00:00

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