Linkage for PrEP/PEP navigation or Hepatitis C treatment navigation for those living in the State of Wyoming.

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For patients in need of assistance navigating PrEP/PEP access or hepatitis C treatment access.

Navigation assistance includes both finding a prescriber and finding cost coverage assistance for the medication(s) when it is available.

I understand that this service is only available to people currently living in the State of Wyoming. *

Yes

Patient currently resides in the State of Wyoming. *

Yes

Wyoming 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: *

Self/patient

CDU staff member

County public health staff member

Federally Qualified Health Center staff member

Title X Clinic staff member

College or university health care staff member

Private medical practice staff member

Community based organization staff member

Jail/corrections staff member

Other:

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 in the State of Wyoming *

Patient's city in the State of Wyoming *

Patient's zip code in the State of Wyoming *

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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