Linkage for PrEP/PEP navigation or Hepatitis C treatment navigation.

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County patient resides in *

Referral for (check all that apply): *

HIV Pre-exposure Prophylaxis (PrEP)

Hepatitis C linkage and treatment

HIV Post-Exposure Prophylaxis (PEP) - within 72 hours of HIV exposure CALL 303.962.4517 to report

Required

Referral made by: *

Patient's insurance status? *

First name of patient *

Last name of patient *

Best way to contact the patient? *

Patient's primary phone number *

Patient's email address

Patient's mailing address *

Patient's mailing address city *

Patient's mailing address zip code *

Patient's date of birth *

YYYY

Name of your organization if you are not the patient

Your name, if you are not the patient

Your email address, if you are not the patient

Your contact phone number, if you are not the patient

Additional information if applicable

Please be aware that we utilize Colorado Health Network (CHN) to provide this service to our Wyoming population and the CHN Navigator will contact you using a Colorado phone number.

Thank you!

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