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

Mission: With a smile and a helping hand, we provide quality care and service to our communities.

Vision: We will distinguish ourselves as the trusted healthcare destination.
We will provide compassionate healthcare and advocate wellness through innovative access, preventive medicine,
and collaborative partnerships within our diverse community.

OUR LOCATIONS

Rio Grande Hospital

310 County Road 14
Del Norte, CO 81132
Tel: 719-657-2510
Open: 24/7

Creede Family Practice

802 Rio Grande
Creede, CO 81130
Tel: 719-658-0929

Rio Grande
Hospital Clinic

310C County Road 14
Del Norte, CO 81132
Tel: 719-657-2418

Monte Vista Medical Clinic & Pharmacy

1033 2nd Avenue
Monte Vista, CO 81144
Tel: 719-852-8827
Pharmacy Tel: 719-628-0533

Rio Grande Hospital Clinic at South Fork

52 Jackson Street
South Fork, CO 81154
Tel: 719-873-5494