BCAP Request for Care Services Form

Please fill out the request for care services form and click the Submit Form button at the end. This will email the Case Management Coordinator with your application.

If you prefer, you may print the form and mail/fax it to BCAP. Click here to download a PDF copy of the application.

Name
Phone #
Do you need a bilingual case manager to call you back?

When a case manager calls you to schedule your initial appointment, is it okay to leave a detailed
message identifying that the call is from BCAP?
If requested, the call from the case manager will be confidential.  She/he will not mention they are from BCAP to anyone answering the phone or on voice mail.

How did you hear about BCAP?

health care provider
jail, police, justice system

other agency
self

family / friend
      other

What is the immediate need that brings you to BCAP at this time?

general case management services
medical care / prescriptions
financial assistance		 housing assistance / homeless
insurance
HIV information
other

Note to the person making referral:

  • If an individual appears to be in crisis, you may ask for an available BCAP case manager. If a case manager is not available, please assure the caller that he or she will be contacted by a case manager within two business days. You can also offer the caller:
    24-hour  Suicide/Crisis Line -- Mental Health Center
    303-447-1665 (Boulder) or 303-684-0555 (Longmont)
  • If the referral is being taken over the phone, read the list of items that caller needs to bring to intake appointment.
  • If the referral is being made in person, print the bottom of this page and give it to the person requesting the referral.
BRING THE FOLLOWING PAPERWORK TO YOUR INITIAL APPOINTMENT:
  • Proof of diagnosis – (copy of labs with T-cell count and viral load; written statement from
    clinic or physician)
  • Proof of residence (i.e., utility or phone bill, lease)
  • Current I.D. (i.e., Colorado i.d.; driver’s license)
  • Insurance information (Medicaid, Medicare, private insurance card) or CICP card
  • Financial information (SSI/SSDI award letter, TPQY, or pay stub)
A case manager will call you within two business days to set up an appointment.

Submit Form