DEPARTMENT OF REGULATORY AGENCIES RESPIRATORY THERAPY RULES AND REGULATIONS 4 CCR 741-1 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________

1.1 Authority

These regulations are adopted pursuant to the authority in sections 12-20-204(1) and 12-300-115, C.R.S., and is intended to be consistent with the requirements of the State Administrative Procedures Act, section 24-4-101 et seq. (the “APA”), C.R.S., and the Respiratory Therapy Practice Act, sections 12-300- 101 et seq. (the “Act”), C.R.S.

1.2 Scope and Purpose

These regulations shall govern the process to become a respiratory therapist and the practice of respiratory therapy in Colorado.

1.3 Oxygen Deliveries

The purpose of this Rule is to define the respiratory therapy services that can be rendered by an unlicensed person delivering oxygen supplies as exempted from the practice of respiratory therapy in section 12-300-112(1)(e), C.R.S.

A. An unlicensed delivery person can deliver, setup, inspect and maintain an oxygen apparatus in a patient's home. An unlicensed delivery person may also instruct the patient about the apparatus' operation.

B. An unlicensed delivery person may not perform pulse oximetry testing, interpret or report physician orders, titrate the oxygen level, discuss disease status with the patient, or engage in any other task or duty that constitutes the practice of respiratory therapy as defined in section 12- 300-104(3), C.R.S.

C. This Rule does not pertain to other licensed health-care professionals practicing within the permitted scope of their profession.

1.4 Declaratory Orders

The purpose of this Rule is to establish procedures for the handling of requests for declaratory orders filed pursuant to the Colorado Administrative Procedures Act at section 24-4-105(11), C.R.S.

A. Any person or entity may petition the Director for a declaratory order to terminate controversies or to remove uncertainties as to the applicability of any statutory provision or of any rule or order of the Director.

B. The Director will determine, at her discretion and without notice to petitioner, whether to rule upon any such petition. If the Director determines that she will not rule upon such a petition, the Director shall promptly notify the petitioner of her action and state the reasons for such decision.

C. In determining whether to rule upon a petition filed pursuant to this Rule, the Director will consider the following matters, among others:

1. 1. Whether a ruling on the petition will terminate a controversy or remove uncertainties as to the applicability to petitioner of any statutory provisions or rule or order of the Director.
2. 2. Whether the petition involves any subject, question or issue that is the subject of a formal or informal matter or investigation currently pending before the Director or a court involving one or more of the petitioners.
3. 3. Whether the petition involves any subject, question or issue that is the subject of a formal or informal matter or investigation currently pending before the Director or a court but not involving any petitioner.
4. 4. Whether the petition seeks a ruling on a moot or hypothetical question or will result in an advisory ruling or opinion.
5. 5. Whether the petitioner has some other adequate legal remedy, other than an action for declaratory relief pursuant to CRCP 57, which will terminate the controversy or remove any uncertainty as to the applicability to the petitioner of the statute, rule or order in question.

D. Any petition filed pursuant to this Rule shall set forth the following:

1. 1. The name and address of the petitioner and whether the petitioner is registered pursuant to Title 12, Article 300.
2. 2. The statute, rule or order to which the petition relates.
3. 3. A concise statement of all of the facts necessary to show the nature of the controversy or uncertainty and the manner in which the statute, rule, or order in question applies or potentially applies to the petitioner.

E. If the Director determines that she will rule on the petition, the following procedures shall apply:

1. 1. The Director may rule upon the petition based solely upon the facts presented in the petition. In such a case:
   1. a. Any ruling of the Director will apply only to the extent of the facts presented in the petition and any amendment to the petition.
   2. b. The Director may order the petitioner to file a written brief, memorandum or statement of position.
   3. c. The Director may set the petition, upon due notice to petitioner, for a non- evidentiary hearing.
   4. d. The Director may dispose of the petition on the sole basis of the matters set forth in the petition.
   5. e. The Director may request the petitioner to submit additional facts in writing. In such event, such additional facts will be considered as an amendment to the petition.
   6. f. The Director may take administrative notice of facts pursuant to the Administrative Procedure Act at section 24-4-105(8), C.R.S., and may utilize her experience, technical competence and specialized knowledge in the disposition of the petition.
2. 2. If the Director rules upon the petition without a hearing, she shall promptly notify the petitioner of her decision.
3. 3. The Director may, at her discretion, set the petition for hearing, upon due notice to petitioner, for the purpose of obtaining additional facts or information or to determine the truth of any facts set forth in the petition or to hear oral argument on the petition. The notice to the petitioner shall set forth, to the extent known, the factual or other matters into which the Director intends to inquire.
   1. For the purpose of such a hearing, to the extent necessary, the petitioner shall have the burden of proving all of the facts stated in the petition; all of the facts necessary to show the nature of the controversy or uncertainty; and the manner in which the statute, rule, or order in question applies or potentially applies to the petitioner and any other facts the petitioner desires the Director to consider.

F. The parties to any proceeding pursuant to this Rule shall be the Director and the petitioner. Any other person may seek leave of the Director to intervene in such a proceeding, and leave to intervene will be granted at the sole discretion of the Director. A petition to intervene shall set forth the same matters as are required by Section (D) of this Rule. Any reference to a “petitioner” in this Rule also refers to any person who has been granted leave to intervene by the Director.

G. Any declaratory order or other order disposing of a petition pursuant to this Rule shall constitute agency action subject to judicial review pursuant to the Colorado Administrative Procedures Act at section 24-4-106, C.R.S.

1.5 Requirement for Reinstatement

The purpose of this Rule is to state the requirements for reinstatement of a license that expired under sections 12-300-108 and 12-20-202, C.R.S.

A. An applicant seeking reinstatement of an expired license shall complete the reinstatement application and pay the reinstatement fee.

B. If the license has been expired for more than two years from the date of receipt of the reinstatement application, but less than five years the applicant will have to establish “competency to practice” under section 12-20-202(2)(c)(II), C.R.S., as follows by submitting:

1. 1. Verification of licensure in good standing from another state along with proof of active practice in that state for two years of the previous five years from the date of application for reinstatement; OR 2. Documentation to demonstrate that they have otherwise maintained competency as a respiratory therapist by completing 30 hours of continuing education courses related to the practice of respiratory therapy during the two years immediately preceding the application for reinstatement. The continuing education must meet the approval of and shall be attested to in the manner prescribed by the Director; OR 3. Documentation to demonstrate that the applicant re-took and achieved a passing score on the National Examination within two years immediately preceding submission of an application for reinstatement; OR 4. By any other means approved by the Director.

C. An applicant seeking to reinstate a license that has been expired for more than five years will need to demonstrate “competency to practice” as required in section 12-20-202(2)(c)(II), C.R.S. by:

1. 1. Verification of licensure in good standing from another state along with proof of active practice for two years of the previous five years prior to an application for reinstatement; OR 2. Supervised practice for a period no less than six months subject to the terms established by the Director; OR 3. Retaking and achieving a passing score on the National Examination within two years immediately preceding submission of an application for reinstatement; OR 4. By any other means approved by the Director.

1.6 Reporting Convictions and Other Adverse Actions

The purpose of the Rule is to clarify the procedures for reporting convictions, and other adverse actions to include judgments and administrative proceedings pursuant to section 12-300-109, C.R.S. A licensee shall inform the Director within thirty days of any of the following events:

A. The licensee has been convicted of or has entered and had accepted by a court a plea of guilty or nolo contendere to a felony under the laws of any state or of the United States which would be a violation of section 12-300-109(2)(b), C.R.S.

B. A disciplinary action imposed upon the licensee by another jurisdiction that licenses respiratory therapists which would be a violation of section 12-300-109(2)(d), C.R.S.

C. Revocation or suspension by another state board, municipality, federal or state agency of any health service related license, other than an expired license for respiratory therapy as described in section 12-300-109(2)(p), C.R.S.

D. Any judgment, award or settlement or a civil action or arbitration in which there was a final judgment or settlement against the licensee for malpractice of respiratory therapy.

E. The notice to the Director shall include the following information:

1. 1. If the event is an action by governmental agency (as described above), the name of the agency, its jurisdiction, the case name, and the docket, proceeding or case number by which the event is designated, and a copy of the consent decree, or decision.
2. 2. If the event is a felony conviction, the court, its jurisdiction, the case name, the case number, a description of the matter or a copy of the indictment or charges, and any plea of verdict entered by the court. The licensee shall also provide to the Director a copy of the imposition of sentence related to the felony conviction and the completion of all terms of the sentence with in ninety days of such action.
3. 3. If the event concerns a civil action or arbitration proceeding, the court or arbiter, the jurisdiction, the case name, the case number, a description of the matter or a copy of the complaint, and a copy of the verdict, the court or arbitration decision, or, if settled, the settlement agreement and court’s order of dismissal.

F. The licensee notifying the Director may submit a written statement with the notice to be included in the licensee’s records.

1.7 Duty to Report Information to the Director’s Office

The purpose of this Rule is to clarify the requirement of licensees to notify the Director of a change in submitted information pursuant to section 24-34-107, C.R.S.

A. The licensee shall inform the Office of Respiratory Therapy Licensure in clear, explicit and unambiguous written statement of any name, address, telephone or email change within 30 days of the change. The Office of Respiratory Therapy Licensure will not change licensees’ information without explicit written notification from the licensee. Notification by any manner approved by the Office of Respiratory Therapy Licensure is acceptable.

1. 1. The Division of Professions and Occupations (“Division”) maintains one contact address for each licensee, regardless of the number of licenses the licensee may hold.
2. 2. Address change requests for some, but not all communications, or for confidential communications only, are not accepted.

B. The Office of Respiratory Therapy Licensure requires one of the following forms of documentation to change a licensee’s name or correct a social security number or individual taxpayer identification number:

1. 1. Marriage license;
2. 2. Divorce decree;
3. 3. Court order;
4. 4. Documentation from the Internal Revenue Service verifying the licensee’s valid individual taxpayer identification number; or 5. Driver’s license or social security card with a second form of identification may be acceptable at the discretion of the Division.

1.8 Licensure Requirements: Credit for Military Experience

The purpose of this Rule is to outline the conditions and procedures governing the evaluation of an applicant’s military training and experience under section 12-20-202(4), C.R.S.

A. An applicant for licensure as a respiratory therapist may submit information about the applicant’s education, training, or experience acquired during military service. It is the applicant’s responsibility to provide timely and complete information for the Director’s review.

B. In order to meet the requirements for licensure, such education, training, or experience must be substantially equivalent to the required qualifications that are otherwise applicable at the time the application is received by the Director.

C. The Director will determine, on a case by case basis, whether the applicant’s military education, training, or experience meet the requirements for certification.

1.9 Duty to Self-Report Certain Medical Conditions

The purpose of this Rule is to specify the notification requirements regarding a physical or mental illness or condition that affects a license holder’s ability to practice respiratory therapy or practice as a respiratory therapist with reasonable skill and safety to patients, pursuant to section 12-300-111, C.R.S.

A. No later than thirty days from the date a physical or mental illness or condition impacts a licensed respiratory therapist’s ability to perform respiratory therapy services with reasonable skill and safety, the licensed respiratory therapist shall provide the Director, in writing, the following information:

1. 1. The diagnosis and a description of the illness or condition;
2. 2. The date that the illness or condition was first diagnosed;
3. 3. The name of the current treatment provider and documentation from the current treatment provider confirming the diagnosis, date of onset, and treatment plan; and 4. A description of the respiratory therapist’s practice and any modifications, limitations or restrictions to that practice that have been made as a result of the illness or condition.

B. The licensed respiratory therapist shall notify the Director of any worsening of the illness or condition, or any significant change in the illness or condition that affects the licensed respiratory therapist’s ability to practice with reasonable skill and safety, within thirty days of the change of the illness or condition. The respiratory therapist shall provide to the Director, in writing, the following information:

1. 1. The name of the current treatment provider, documentation from the current treatment provider confirming the change of the illness or condition, the date that the illness or condition changed, the nature of the change of the illness or condition, and the current treatment plan; and 2. A description of the licensed respiratory therapist’s practice, and any modifications, limitations, or restrictions to that practice that have been made as a result of the change of condition.

C. Compliance with this Rule is a prerequisite for eligibility to enter into a Confidential Agreement with the Director pursuant to section 12-300-111, C.R.S. However, mere compliance with this Rule does not require the Director to enter into a Confidential Agreement. Rather, the Director will evaluate all facts and circumstances to determine whether a Confidential Agreement is appropriate.

D. If the Director discovers that a licensed respiratory therapist has a mental or physical illness or condition that affects the licensed respiratory therapist’s ability to practice with reasonable skill and safety, and the licensed respiratory therapist did not timely notify the Director of such illness or condition, the licensed respiratory therapist may be subject to disciplinary action pursuant to section 12-300-109(2)(i), C.R.S.

1.10 Concerning Health Care Provider Disclosures to Consumers about the Potential Effects of Receiving Emergency or Nonemergency Services from an Out-of-Network Provider This Rule is promulgated and adopted by the Director of the Division of Professions and Occupations (“Director”), pursuant to the rulemaking authority in sections 12-20-204, 12-300-115, and 24-34-113(3), C.R.S., in consultation with the Commissioner of Insurance and the State Board of Health under the authority of section 24-34-113(2), C.R.S.

The purpose of this Rule is to establish requirements for health care providers to provide disclosures to consumers about the potential effects of receiving emergency or non-emergency services from an out-of- network provider as required by section 24-34-113(2), C.R.S. This Rule applies to health care providers as defined in sections 24-34-113(1)(f) and 10-16-102(56), C.R.S.

A. Disclosure requirements. Pursuant to section 24-34-113, C.R.S., health care providers shall provide the disclosure contained in Appendix A to all clients about the potential effects of receiving emergency or nonemergency services from an out-of-network facility or agency or an out-of-network provider who provides services at an in-network facility or agency. The health care provider shall provide the disclosure contained in Appendix A at all of the following occasions:

1. 1. For emergency services: after performing an appropriate screening examination and after determining that a client does not have an emergency medical condition or after treatment has been provided to stabilize an emergency medical condition. The disclosure shall be signed by the client or their designated representative prior to discharge;
2. 2. At the time the client consents to care or treatment by the health care provider for nonemergency services. The disclosure shall be signed by the client or their designated representative before the start of services;
3. 3. On billing statements and billing notices issued by the health care provider; and 4. On other forms or communications related to the services being provided pursuant to insurance coverage.

B. Noncompliance with this Rule may result in the imposition of any of discipline made available by section 12-300-109(2)(g), C.R.S.

1.9 EXPANDED DELEGATION PURSUANT TO THE GOVERNOR’S EXECUTIVE ORDER D 2022

A. Through Executive Order D 2022 010, amending and extending Executive Orders D 2021 122, D 2021 124, D 2021 125, D 2021 129, D 2021 132, D 2021 136, D 2021 139, D 2021 141, and D 2022 003, Governor Jared Polis directed the Executive Director of DORA, through the Director of the Division of Professions and Occupations (Division Director), to promulgate and issue temporary emergency rules consistent with the Executive Order. The basis for these emergency rules is Executive Order D 2022 010 issued by Governor Jared Polis pursuant to the Colorado COVID-19 Disaster Recovery Order and Article IV, Section 2 of the Colorado Constitution, and the Colorado Disaster Emergency Act, sections 24-33.5-701, et. seq., C.R.S.

B. These Emergency Rules are adopted by the Director of the Division of Professions and Occupations (Director) to effectuate Executive Order D 2022 010, amending and extending Executive Orders D 2021 122, D 2021 124, D 2021 125, D 2021 129, D 2021 132, D 2021 136, D 2021 139, D 2021 141, and D 2022 003, and directing the immediate expansion of the workforce of trained medical personnel available to provide healthcare services within inpatient facilities due to the coronavirus disease 2019 (COVID-19) pandemic in Colorado.

C. Expanded Delegation

1. 1. In addition to any delegation authorized by section 12-300-112(1)(i), C.R.S., respiratory therapists may delegate services within their scope of practice to the following Colorado licensed professionals working in a hospital or inpatient facility:
   1. a. Podiatrists b. Optometrists c. Chiropractors d. Veterinarians e. Physical Therapists f. Physical Therapy Assistants g. Occupational Therapists h. Occupational Therapy Assistants i. Speech-Language Pathologists j. Surgical Assistants k. Surgical Technologists l. Volunteer Retired Nurses m. Nurse Aides
2. 2. Respiratory therapists may delegate services within their scope of practice to the following unlicensed persons working in a hospital or inpatient facility:
   1. a. Volunteer Nursing Students b. Medical Assistants
3. 3. In addition to the provisions of section 12-300-112(1)(i), C.R.S., respiratory therapists are authorized to provide training to the Colorado licensed professionals and unlicensed persons set forth in Rule 1.10(C)(1) and(2).
4. 4. In order to delegate services pursuant to Rule 1.10(C)(1) and (2), the Respiratory Therapist shall ensure, prior to the delegation, that the delegated service is within the knowledge, skill and training of the delegatee.
5. 5. The respiratory therapists shall ensure on-premises availability to provide direction and supervision of the delegatee.
6. 6. The delegated services shall be routine, technical services, the performance of which do not require the special skill or decision making ability of a respiratory therapist.
7. 7. The prescription or selection of medications, performance of surgical or other invasive procedures and anesthesia services may not be delegated.

1.10 EXPANDED SCOPE OF PRACTICE FOR RESPIRATORY THERAPISTS IN ORDER TO

1. ADMINISTER VACCINATIONS PURSUANT TO THE GOVERNOR’S EXECUTIVE ORDER D 2022 010

A. Basis. Through Executive Order D 2022 010, amending and extending Executive Orders D 2021 122, D 2021 124, D 2021 125, D 2021 129, D 2021 132, D 2021 136, D 2021 139, D 2021 141, and D 2022 003, Governor Jared Polis directed the Executive Director of DORA, through the Director of the Division of Professions and Occupations (Division Director), to promulgate and issue temporary emergency rules consistent with the Executive Order. The basis for these emergency rules is Executive Order D 2022 010 issued by Governor Jared Polis pursuant to the Colorado COVID-19 Disaster Recovery Order and Article IV, Section 2 of the Colorado Constitution, and the Colorado Disaster Emergency Act, sections 24-33.5-701, et. seq., C.R.S.

B. Purpose. These Emergency Rules are adopted by the Executive Director of DORA, through the Division Director, to effectuate Executive Order D 2022 010, amending and extending Executive Orders D 2021 122, D 2021 124, D 2021 125, D 2021 129, D 2021 132, D 2021 136, D 2021 139, D 2021 141, and D 2022 003, and directing the immediate expansion of the workforce of trained medical personnel available to administer the coronavirus disease 2019 (COVID-19) vaccinations within inpatient facilities and outpatient settings due to the coronavirus disease 2019 (COVID-19) pandemic in Colorado.

C. Expanded Scope of Practice In Order to Administer the COVID-19 Vaccination.

1. 1. Respiratory therapists may administer the COVID-19 vaccination while working in a hospital, inpatient facility or outpatient setting as delegated by physicians, physician assistants, advanced practice registered nurses, certified registered nurse anesthetists, or professional nurses.
   1. a. Respiratory therapists are authorized to perform this delegated service upon adequate cross-training as determined necessary by the hospital, inpatient facility, or outpatient setting.
   2. b. Respiratory therapists shall not accept delegation of this service if the licensee does not possess the knowledge, skill or training to perform.
   3. c. Respiratory therapists shall not perform this delegated service if the licensee does not possess the knowledge, skill or training to perform.
   4. d. This delegated service shall not be re-delegated to another person or licensee by the delegatee.
   5. e. Respiratory therapists shall not prescribe, order, or select the COVID-19 vaccination regardless of delegation.

1.11 REQUIRED DISCLOSURE TO PATIENTS – CONVICTION OF OR DISCIPLINE BASED ON

1. SEXUAL MISCONDUCT (§12-30-115, C.R.S.)

A. On or after March 1, 2021, a provider, shall disclose to a patient, as defined in section 12-30- 115(1)(a), C.R.S., instances of sexual misconduct , including a conviction or guilty plea as set forth in section 12-30-115 (2)(a) C.R.S., or final agency action resulting in probation or limitation of the provider’s ability to practice as set forth is section 12-30-115(2)(b), C.R.S.

B. Form of Disclosure: The written disclosure shall include all information specified in section 12-30- 115(3), C.R.S., and consistent with the sample model disclosure form as set forth in Appendix B to these rules. The patient must, through his or her signature on the disclosure form, acknowledge the receipt of the disclosure and agree to treatment with the provider.

C. Timing of Disclosure: This disclosure shall be provided to a patient the same day the patient schedules a professional services appointment with the provider. If an appointment is scheduled the same day that services will be provided or if an appointment is not necessary, the disclosure must be provided in advance of the treatment.

1. 1. The written disclosure and agreement to treatment must be completed prior to each treatment appointment with a patient unless the treatment will occur in a series over multiple appointments or a patient/patient schedules follow-up treatment appointments.
2. 2. For treatment series or follow-up treatment appointments, one disclosure prior to the first appointment is sufficient, unless the information the provider is required to disclose pursuant to section 12-30-115, C.R.S., has changed since the most recent disclosure, in which case an updated disclosure must be provided to a patient and signed before treatment may continue.

D. As set forth in section 12-30-115(3)(e), C.R.S., the requirement to disclose the conviction, guilty plea, or agency action ends when the provider has satisfied the requirements of the probation or other limitation and is no longer on probation or otherwise subject to a limitation on the ability to practice the provider’s profession.

E. A provider need not make the disclosure required by this section before providing professional services to the patient if any of the following applies as set forth in section 12-30-115(4), C.R.S.:

1. 1. The patient is unconscious or otherwise unable to comprehend the disclosure and sign an acknowledgment of receipt of the disclosure pursuant to section 12-30-115(3)(d), C.R.S., and a guardian of the patient is unavailable to comprehend the disclosure and sign the acknowledgment;
2. 2. The visit occurs in an emergency room or freestanding emergency department or the visit is unscheduled, including consultations in inpatient facilities; or 3. The provider who will be treating the patient during the visit is not known to the patient until immediately prior to the start of the visit.

F. The provider who does not have a direct treatment relationship or have direct contact with the patient is not required to make the disclosure required by this section. APPENDIX A Surprise Billing – Know Your Rights Beginning January 1, 2020, Colorado state law protects you* from “surprise billing,” also known as “balance billing.” These protections apply when:

• You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or • You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado What is surprise/balance billing, and when does it happen? If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing. When you CANNOT be balance-billed:

Emergency Services If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost- sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.

Nonemergency Services at an In-Network or Out-of-Network Health Care Provider The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider.

You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.

Additional Protections • Your insurer will pay out-of-network providers and facilities directly. • Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit. • Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.

• No one, including a provider, hospital, or insurer can ask you to limit or give up these rights. If you receive services from an out-of-network provider or facility or agency OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive nonemergency services from an out-of-network provider or facility, you may also be balance billed.

If you want to file a complaint against your health care provider, you can submit an online complaint by visiting this website: https://www.colorado.gov/pacific/dora/DPO_File_Complaint. If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894- 7490 or 1-800-930-3745.

*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.

Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.

APPENDIX B MODEL SEXUAL MISCONDUCT DISCLOSURE STATEMENT DISCLAIMER: This Model Sexual Misconduct Disclosure Statement is to be used as a guide only and is aimed only to assist the practitioner in complying with § 12-30-115, C.R.S., and the rules promulgated pursuant to this statute by the Director. As a licensed, registered, and/or certified health care provider in the State of Colorado, you are responsible for ensuring that you are in compliance with state statutes and rules. While the information below must be included in your Sexual Misconduct Disclosure Statement pursuant to § 12-30-115, C.R.S., you are welcome to include additional information that specifically applies to your situation and practice.

A. Provider information, including, at a minimum: name, business address, and business telephone number.

B. A listing of any final convictions of or a guilty plea to a sex offense, as defined in § 16-11.7- 102(3), C.R.S.

C. For each such conviction or guilty plea, the provider shall provide, at a minimum:

1. 1. The date that the final judgment of conviction or guilty plea was entered;
2. 2. The nature of the offense or conduct that led to the final conviction or guilty plea;
3. 3. The type, scope, and duration of the sentence or other penalty imposed, including whether:
   1. a. The provider entered a guilty plea or was convicted pursuant to a criminal adjudication;
   2. b. The provider was placed on probation and, if so, the duration and terms of the probation and the date the probation ends; and, c. The jurisdiction that imposed the final conviction or issued an order approving the guilty plea.]

D. A listing of any final agency action by a professional regulatory board or agency that results in probationary status or other limitation on the provider’s ability to practice if the final agency action is based in whole or in part on:

1. 1. a conviction for or a guilty plea to a sex offense, as defined in section 16-11.7-102(3), C.R.S., or a finding by the professional regulatory board or Director that the provider committed a sex offense, as defined in as defined in section 16-11.7-102(3), C.R.S.; OR 2. a finding by a professional regulatory board or agency that the provider engaged in unprofessional conduct or other conduct that is grounds for discipline under the part or article of Title 12 of the Colorado Revised Statutes that regulates the provider’s profession, where the failure or conduct is related to, includes, or involves sexual misconduct that results in harm to a patient or presents a significant risk of public harm to patients..

E. For each such final agency action by a professional regulatory board or agency the provider shall provide, at a minimum:

1. 1. The type, scope, and duration of the agency action imposed, including whether:
   1. a. the regulator and provider entered into a stipulation;
   2. b. the agency action resulted from an adjudicated decision;
   3. c. the provider was placed on probation and, if so, the duration and terms of probation; and d. the professional regulatory board or agency imposed any limitations on the provider’s practice and, if so, a description of the specific limitations and the duration of the limitations.
2. 2. The nature of the offense or conduct, including the grounds for probation or practice limitations specified in the final agency action;
   1. a. The date the final agency action was issued b. The date the probation status or practice limitation ends; and c.. The contact information for the professional regulatory board or agency that imposed the final agency action on the provider, including information on how to file a complaint.

Sample Signature Block I have received and read the sexual misconduct disclosure by [Provider Name] and I agree to treatment by [Provider Name].

_______________________________________________________________ Print Client Name _______________________________________________________________ Client or Responsible Party’s Signature Date If signed by Responsible Party (parent, legal guardian, or custodian), print Responsible Party’s name and relationship to client:

_______________________________________________________________ Print Responsible Party Name Print Relationship to Client _______________________________________________________________ Provider Signature Date _________________________________________________________________________ Editor’s Notes History Entire rule eff. 05/01/2010.

Basis, Rules 2.A., 5.A.1., 6, 7, eff. 01/30/2017.

Rule 1.8, Appendix A emer. rules eff. 01/01/2020; expired 04/29/2020. Rule 1.8, Appendix A eff. 04/30/2020.

Rule 1.9 emer. rule eff. 05/01/2020; expired 08/29/2020. Rule 1.10 emer. rule eff. 05/11/2020; expired 09/08/2020. Rule 1.9 emer. rule eff. 08/30/2020.

Rule 1.10 emer. rule eff. 09/09/2020.

Rules 1.1-1.11, Appendices A, B eff. 12/15/2020.

Rules 1.9, 1.10 emer. rules eff. 12/28/2020.

Rule 1.11 emer. rule eff. 01/11/2021.

Rules 1.9, 1.10 emer. rules eff. 04/27/2021.

Rule 1.11 emer. rule eff. 05/11/2021.

Rules 1.11 E-F eff. 05/30/2021.

Rules 1.9, 1.10 emer. rules eff. 07/12/2021.

Rules 1.9, 1.10 emer. rules eff. 11/02/2021.

Rule 1.7 B eff. 11/14/2021.

Rules 1.9, 1.10 emer. rules eff. 03/02/2022.

Annotations Rule 1.11 E.4 (adopted 10/21/2020) was not extended by Senate Bill 21-152 and therefore expired 05/15/2021.