4 CCR 726-1
DEPARTMENT OF REGULATORY AGENCIES SOCIAL WORK EXAMINERS RULES AND REGULATIONS 4 CCR 726-1 [Editor's Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ AUTHORITY These Rules are promulgated pursuant to sections 12-20-204(1), 12-245-204(4)(a) and 12-245-222(2), C.R.S.
The licensing and regulation of Mental Health Professionals is found in Title 12 (“Professions and Occupations”), Article 245 (“Mental Health”) of the Colorado Revised Statutes (“Mental Health Practice Act”). Article 245 consists of eight parts summarized, as applicable, as follows: Part Name of Part Statutes in Part Part 1 Legislative Declaration 12-245-101 Part 2 General Provisions 12-245-202 - 12-245-234 Part 4 Social Workers 12-245-401 - 12-245-411 Part 2 contains general provisions applicable to all Mental Health Professionals. Part 4 applies specifically to social workers.
PURPOSE AND SCOPE These Rules were promulgated in order to carry out the powers and duties of the Colorado State Board of Social Work Examiners, pursuant to sections 12-20-204(1) and 12-245-402, C.R.S. These Rules affect every person seeking Colorado licensure as a social worker and every person who practices as a licensed social worker or a licensed clinical social worker, and who is not statutorily exempted.
1.1 DEFINITIONS
In addition to the definitions set out in sections 12-245-202 and 12-245-401, C.R.S., unless the context requires otherwise, as used in these Rules:
A. “Active practice of Social Work” means all services included within the definition of social work practice as defined in section 12-245-403, C.R.S., and as otherwise identified in these Rules.
B. The “Board” means the State Board of Social Work Examiners established pursuant to section 12-245-402, C.R.S.
C. “Director” means the Board's Program Director and staff.
D. “Employment counseling” means professional activities that are provided on a short-term basis and that are intended to assist individuals with locating, applying for, interviewing, or otherwise successfully securing paid employment.
E. “License in good standing” means a license that is not restricted in any fashion.
F. “Licensee” as contemplated under section 12-245-225(2), C.R.S., shall include any person who has been licensed as a licensed social worker, a licensed clinical social worker, or a clinical social workers candidate at any time under the Mental Health Practice Act pursuant to section 12-245- 401, et seq., C.R.S.
G. “Rehabilitation counseling” means professional activities that are intended to assist a person with a physical handicap, defect, or injury as defined in sections 26-8-105(2)(a), (b), or (c), C.R.S., to learn or to relearn to perform routine daily functions including, but not limited to, eating, dressing, transportation, or employment.
1.2 PUBLIC PARTICIPATION AT BOARD MEETINGS (C.R.S. §§ 12-20-204(1), 12-245-204, 12- 245-222)
A. The Board may provide a person a reasonable opportunity to address the Board at an open meeting if the request is made prior to the meeting in accordance with this Rule and, in the Board's sole discretion, the granting of the request will not result in delay or disruption of the Board's meeting.
B. Except in unusual circumstances and in the Board's sole discretion, the Board will rely exclusively on written materials during its initial consideration of inquiries and shall not permit members of the public to address the Board on pending disciplinary proceedings or cases.
C. The Board may impose reasonable limitations on the time allotted for comments made pursuant to this Rule.
1.3 CONFIDENTIALITY OF PROCEEDINGS AND RECORDS OF THE BOARD (C.R.S. §§ 12-245-
220, 12-245-222, 12-245-226(4))
A. General. Inquiries, complaints, investigations, hearings, meetings, or any other proceedings of the Board relating to disciplinary proceedings shall not be open to public inspection until the Board meets for its initial consideration of the inquiry that gave rise to the proceedings. The initial consideration of the inquiry and all further proceedings shall be open and the records available for inspection unless subsection (B) of this Rule, an exception to the Public Records Act, or an exception to the Open Meetings Act applies or section 12-245-226(4), C.R.S., prohibits disclosure.
B. Subpoenaed Information. Information subpoenaed by the Board shall remain confidential and not be open to public inspection until the Board has reviewed the information and made a determination whether the information should remain confidential. Information which is not determined to be confidential shall be open to public inspection unless an exception to subsection (a) an exception to the Public Records Act or the Open Meetings Act applies or section 12-245- 226(4), C.R.S., prohibits disclosure. This exception shall not apply to review of information by a respondent in a Board investigation.
1.4 DECLARATORY ORDERS (C.R.S. § 24-4-105(11))
A. Any person may petition the Board for a declaratory order to terminate a controversy or to remove uncertainty as to the applicability to the petitioner of any statutory provision or of any Board Rule or Order.
B. A petition filed pursuant to this Rule shall set forth the following:
1. The name and address of the petitioner and whether the petitioner is a Licensee;
2. The Statute, Rule, or Order to which the petition relates; and 3. A concise statement of all 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.
C. The Board will determine, in its discretion and without notice to petitioner, whether to rule on a petition. In determining whether to rule on a petition, the Board will consider the following matters, among others:
1. Whether a ruling on the petition will terminate a controversy or remove uncertainty as to the applicability to petitioner of any statutory provision or Board Rule or Order.
2. Whether the petition involves any subject, question, or issue that is the subject of a formal or informal matter, proceeding, or investigation involving the petitioner and currently pending before the Board, any other agency, or a court.
3. Whether the petition involves any subject, question, or issue that is the subject of a formal or informal matter, proceeding, or investigation currently pending before the Board, any other agency, or a court, but not involving the petitioner.
4. Whether the petition seeks a ruling on a moot or hypothetical question or will result in an advisory ruling or opinion.
5. Whether the petitioner has some other adequate legal remedy, other than an action for declaratory relief pursuant to Rule 57, Colorado Rules of Civil Procedure, that will terminate the controversy or remove any uncertainty as to the applicability to the petitioner of the Statute, Rule, or Order in question.
D. If the Board determines, in its discretion, that it will not rule on the petition pursuant to this Rule, the Board shall promptly notify the petitioner of its action and state the reasons for such action.
E. If the Board determines, in its discretion, that it will rule on the petition, any ruling of the Board will apply only to the facts presented in the petition and any amendment to the petition. If the Board rules on the petition without a hearing, it shall notify the petitioner of its decision, within 120 days. In ruling on the petition, the Board may take one or more of the following actions, in its discretion:
1. The Board may dispose of the petition on the basis of the matters set out in the petition.
2. The Board may request the petitioner to submit additional facts, in writing. In this event, the additional facts amend the petition.
3. The Board may order the petitioner to file a written brief, memorandum, or statement of position.
4. The Board may set the petition for hearing, upon due notice to petitioner, to obtain additional facts or information; 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 setting the hearing shall state, to the extent known, the factual or other matters into which the Board intends to inquire. For the purpose of the hearing, to the extent necessary, the petitioner shall have the burden of proving all facts stated in the petition; all facts necessary to show the nature of the controversy or uncertainty; 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 Board to consider.
F. If the Board determines that the petition addresses a matter within the purview of any other agency, the Board shall refer the petition to the other agency for consideration. If the Board refers a petition to another agency, the Board shall promptly inform the petitioner of the referral. The referral ends the matter before the Board.
G. The parties to any proceeding pursuant to this Rule shall be the Board and the petitioner. Any other person may seek leave of the Board to intervene in such a proceeding. A petition to intervene shall set forth the matters required by subsection (c) of this Rule. Based on the information presented and in its discretion, the Board may grant leave to intervene. Any reference to “petitioner” in this Rule includes any person who has been granted leave to intervene by the Board.
H. Any declaratory order or other order disposing of a petition pursuant to this Rule shall constitute final agency action subject to judicial review pursuant to section 24-4-106, C.R.S.
1.5 MANDATORY DISCLOSURE STATEMENT (C.R.S. §§ 12-245-216, 12-245-224(1)(p))
A. As used in section 12-245-216, C.R.S., and this Rule, 1. “Emergency” means those situations in which, on presentation, the client's condition requires immediate intervention and/or stabilization.
2. “Initial client contact” means the first contact between the social worker and the client. This term does not include client contact that is preliminary to beginning the social worker/client relationship (e.g., contact to determine office hours, methods used, availability). In those instances in which the client is incapable of understanding, disclosure shall be given at the first opportunity such impairment is removed.
1.6 INFORMATION REQUIRED TO BE REPORTED TO THE BOARD (C.R.S. § 12-245-226(8))
A. General. Social workers are required to report violations of section 12-245-224 or 12-245-228, C.R.S., to the appropriate Board once they have direct knowledge that a Licensee, as defined by section 12-245-202(8), C.R.S., a certificate holder as defined by section 12-245-202(2), or a registrant as defined by section 12-245-202(16), C.R.S., has violated a provision of section 12- 245-224 or 12-245-228, C.R.S., to include conversion therapy with a client under the age of 18 years old prohibited per section 12-245-224(1)(t)(V), C.R.S. Social workers are not required to report when reporting would violate client/therapist confidentiality (refer to section 12-245-220, C.R.S.).
B. Terms.
1. “Direct knowledge” includes but is not limited to the following:
2. “Has violated” means a reasonable belief that a Licensee, certified addiction counselor, or Unlicensed Psychotherapist has engaged in a prohibited activity under section 12-245- 224, C.R.S., or the unauthorized practice under section 12-245-228, C.R.S.
C. Procedures.
1. Once direct knowledge is established, the social worker must report the alleged violation as soon as possible or, absent unusual circumstances, no later than sixty days.
2. When direct knowledge of a violation of section 12-245-224 or 12-245-228, C.R.S., is obtained from their client, the social worker shall:
3. The report shall be in writing and shall include the specifics of the violation, to the degree known, and any and all relevant information and supporting documentation.
D. Nothing in this Rule relieves any social worker from adhering to any other mandatory reporting requirements mandated by statute.
1.7 SUPERVISION OF MENTAL HEALTH PRACTITIONERS FOR NON-LICENSURE PURPOSES
AND SUPERVISORY RELATIONSHIPS (C.R.S. §§ 12-245-222(2), 12-245-224(1)(n)) A. General. Supervision provides a source of knowledge, expertise, and more advanced skills to the person being supervised. The nature of this relationship depends on the respective skills of the two professionals involved, the client population and/or the specific client being served. It is usually ongoing, required, and hierarchical in nature. This Rule does not apply to the supervision required prior to licensure as a social worker.
B. Terms.
1. Clinical supervision occurs when there is close, ongoing review and direction of a supervisee's clinical practice.
2. Consultation describes a voluntary relationship between professionals of relative equal expertise or status wherein the consultant offers their best advice or information on an individual case or problem for use by the consultee as s/he deems appropriate in their professional judgment.
3. Administrative supervisor is the person who bears responsibility for the non-clinical functioning of an employee, such as performance appraisals, personnel decisions, etc. The administrative supervisor may be held accountable for not reporting misconduct by a social worker when s/he knew or should have known of a violation of generally accepted standards of practice or any prohibited activity.
4. Modes of Supervision. Include but are not limited to individual, group, telephone, electronic mail, audio-visual, process recording, direct observation, telecommunication (teleconferencing, fax, videotapes), and hospital rounds. The appropriate modality of supervision shall be determined by the training, education, and experience of the supervisee, and the treatment setting (i.e. urban/rural, or the availability of resources and at all times based on community standards and client needs). The level of supervision provided, including whether every case is supervised and whether the supervisor meets with the client, is determined by the education, training, and experience of the supervisee, the specific needs of the clients being served, and the professional judgment of the supervisor. Nothing in this Rule should be assumed to abridge the rights of the client to a reasonable standard of care.
C. Supervision Shall Include But is Not Limited To The Following:
1. Monitoring the supervisee's activities to verify s/he is providing services that meet generally accepted standards of practice.
2. Verifying that it is the practice of any supervisee to provide the mandatory disclosure form as required pursuant to section 12-245-216, C.R.S.
3. If appropriate, verifying that clients are informed as to any changes in the supervisory relationship.
4. Giving an adequate termination of supervision notice to the supervisee.
5. Keeping records that document supervision that meet the generally accepted standards of practice.
6. Assisting the supervisee in becoming aware of and adhering to all legal, ethical, and professional responsibilities.
7. Assuring that no inappropriate relationships exist between the supervisor and supervisee, and supervisor and client.
8. Assuring that no inappropriate relationships exist between the supervisor and supervisee, and supervisor and client.
9. Assisting to assure that the supervisee is in compliance with the Mental Health Practice Act.
10. Verifying and assuring the supervisee is in compliance with any existing restricted licensure, certification or registration status or probation.
D. Supervisor Qualifications.
1. The supervisor shall have sufficient knowledge of legal, ethical, and professional standards relevant to the clients being served.
2. The supervisor shall have clinical experience and competence adequate to perform and direct the services provided by the supervisee.
1.8 REPORTING CHANGE OF ADDRESS, TELEPHONE NUMBER, OR NAME (C.R.S. §§ 12-20-
204(1), 12-245-204, 12-245-206)
A. Licensees shall inform the Division of any name, telephone number or address change within thirty days of such change. Staff shall not change Licensees' information without written notification from the Licensee. Notification via mail, fax, email and the online system is acceptable. Verbal notification is not acceptable.
B. Any of the following documentation is required to change a Licensee's name or correct a social security number or individual taxpayer identification number: marriage license, divorce decree, court order, or documentation from the Internal Revenue Service verifying the licensee’s valid individual taxpayer identification number. A driver's license or social security card with a second form of identification may be acceptable at the discretion of the Director of Support Services.
1.9 DUPLICATE OR REPLACEMENT LICENSE (C.R.S. §§ 12-245-206, 12-245-209)
A. Upon licensure and at renewal, the Division will issue only one license to a Licensee. The Division may issue a duplicate license if the Licensee submits a written request along with the required fee.
B. Justification for issuance of a duplicate license may be requested if the original was lost, stolen, damaged, never received, printed with the incorrect information, or if the address or name has changed.
C. A duplicate license may also be issued for those Licensees that require multiple licenses.
1.10 RENEWAL OF LICENSE (C.R.S. § 12-245-205(3))
A. Failure to Receive Renewal Notice. Failure to receive notice for renewal of license from the Board does not excuse a Licensee from the requirement for renewal under the Act and this Rule.
B. Grace period. Licensees shall have a sixty-day grace period after the expiration of their license to renew such license without the imposition of a disciplinary sanction for practicing on an expired license. During this grace period a delinquency fee will be charged for late renewals. A Licensee who does not renew their license within the sixty-day grace period shall be treated as having an expired license and shall be ineligible to practice until such a license is reinstated.
C. Continuing Professional Competence. Pursuant to section 12-245-410, C.R.S., and Board Rule 1.18, effective January 1, 2011, licensed social workers and licensed clinical social workers shall demonstrate continuing professional competence in order to renew.
D. Military Active Duty. Licensees may be exempt from licensing requirements as provided in section 12-20-302, C.R.S.
1.11 AUTHORITY TO INVESTIGATE (C.R.S. §§ 12-20-204, 12-245-204)
An application for initial license, for renewal of a license, or for reinstatement of a license is an express grant to the Board of full authority to make any investigation or personal contact necessary to verify the authenticity of the matters and information stated in the application. If the Board so requests, the applicant must supply verification, documentation and/or complete information on any disciplinary action taken against the applicant in any jurisdiction.
1.12 OCCUPATIONAL CREDENTIAL PORTABILITY PROGRAM (C.R.S. §§ 12-245-207, 12-20-
202(3))
A. General. Effective January 1, 2021, to be considered for licensure by endorsement pursuant to the Occupational Credential Portability Program under sections 12-20-202(3) and 12-245-207, C.R.S., an applicant must submit a completed application form, all supporting documentation, and the appropriate fee.
B. Complaints/inquiries, investigations, disciplinary actions. The Board may decline to issue a license to an applicant for licensure by endorsement pursuant to the Occupational Credential Portability Program if approving the license would violate an existing compact or reciprocity agreement or if the Board demonstrates by a preponderance of the evidence, after notice and opportunity for a hearing, that the applicant:
1. Lacks the requisite substantially equivalent experience or credentials to practice social work; or 2. Has committed an act that would be grounds for disciplinary action under the law governing the practice of social work.
C. Criteria. In accordance with section 12-20-202(3), C.R.S., an applicant who possesses a current and unrestricted license, in good standing, to practice social work in another state or United States’ territory or through the federal government, or holds a military occupational specialty, as defined in section 24-4-201, C.R.S., may apply to the Board for licensure by endorsement pursuant to the Occupational Credential Portability Program. To apply for endorsement, the applicant must satisfy the following criteria:
1. Applicant submits to the Board:
2. Applicant must attest that they:
3. Applicant submits verification of licensure from each jurisdiction(s) in which, and each federal agency and military service branch through which, applicant has ever been licensed, registered, listed or certified. The verification can be retrieved by the applicant from the jurisdiction’s website as long as the following information is included and can be verified if necessary:
If the complete information is not available then the Verification of License Form must be completed by each state, federal agency, or military service branch.
4. Applicant submits proof that he/she is at least twenty-one years of age.
D. Jurisprudence Examination. Each applicant shall pass a Board-developed jurisprudence examination.
1.13 REINSTATEMENT OF AN EXPIRED LICENSE (C.R.S. § 12-245-205)
A. General. A license that has expired is subject to the following reinstatement provisions.
B. Application requirements. To be considered for license reinstatement, an applicant must submit a completed reinstatement application form and the reinstatement fee.
C. Required statements. Each applicant for reinstatement shall certify the following:
1. Every license, certificate, listing or registration to practice social work held by applicant is in good standing;
2. Applicant has reported to the Board any injunction or disciplinary action completed or pending against their license, certificate, registration, or listing to practice social work or psychotherapy;
3. Applicant has reported to the Board any malpractice judgment against them, any settlement of a malpractice action or claim against them, and any malpractice action or claim pending against them where the malpractice alleged relates to their practice of social work or psychotherapy.
4. Applicant has reported to the Board any inquiry/complaint pending, investigation being conducted by, or disciplinary proceeding pending before the licensing, grievance, or disciplinary board of any jurisdiction in which he or she is licensed, certified, registered, or listed to practice social work or psychotherapy in which the complaint, investigation, or proceeding concerns their practice of social work or psychotherapy.
D. The Board may decline to issue a license to an applicant for reinstatement if disciplinary action is pending or if there is an unresolved complaint.
E. Continuing Professional Competence. Pursuant to section 12-245-410, C.R.S., effective January 1, 2011, licensed social workers and licensed clinical social workers shall demonstrate continuing professional competence in order to reinstate.
1. An applicant for reinstatement must comply with all Continuing Professional Development requirements pursuant to Board Rule 1.18 within the two years immediately preceding the application receipt date.
F. Additional criteria for a license expired more than two years. The Board has established the following criteria for determining whether an applicant for reinstatement has demonstrated competency to practice as required by section 12-20-202(2)(c)(II), C.R.S. An applicant must meet all applicable criteria to establish their continued professional competence.
1. License expired more than two years. An applicant whose license has been expired more than two years shall pass a Board approved jurisprudence examination and either:
1.14 LICENSURE BY EXAMINATION (C.R.S. § 12-245-404)
A. Criteria for application.
1. The applicant must submit to the Board a completed application for licensure, all fees, official transcript(s), and all supporting documentation required by the Board in order for the Board to review the application for licensure.
2. Applications for licensure remain active for one (1) year. If the applicant fails to become licensed within this time period, s/he must submit a new application and fee and must meet the educational, experience, and examination requirements in effect at the time of the date of the new application. The Board, in its sole discretion, may extend an application upon written request accompanied by a showing of good cause.
3. An applicant for licensure must pass the required examination no more than five (5) years prior to the date of the application for licensure. Experience and supervision requirements that predate the application by more than five (5) years will not be accepted by the Board absent a showing of good cause, as determined by the Board. However, this may not apply in those exceptions allowable under statute concerning clinical social worker candidates.
4. All applicants for licensure have a continuing obligation to update their application with information changes from the original application at any time prior to licensure.
B. Education and Training Requirements.
1. Accredited Program. The applicant obtained a master's degree in social work from a program that was approved by the Council on Social Work Education (CSWE) or a doctoral degree in social work from a doctoral program within a social work education program accredited by the CSWE.
2. Foreign-trained applicants. Foreign-trained applicants must submit educational credentials to a credentialing agency utilized by the Board for evaluation of equivalency. After course equivalency is established, the Board will evaluate the educational credentials to determine whether or not the program is equivalent by the CSWE.
C. Post-Graduate Experience Requirements. The Board will approve post-master's or post-doctoral supervised practice as meeting the requirements for licensure set out in section 12-245-404(2)(c), C.R.S., when that practice satisfies the requirements of this subsection.
1. Definitions. As used in sections 12-245-403 and 12-245-404(2)(c), C.R.S., and in this Rule, unless the context indicates otherwise:
2. Certification of Completion. Each applicant shall file with the Board a verified statement signed by their approved clinical supervisor, upon forms supplied by the Board, a verified statement signed under penalty of law by their approved supervisor(s) attesting to the applicant's satisfactory completion of the required post-degree work experience and supervision hours towards licensure as defined in Rule 1.14(C)(3) under supervision and attesting to the applicant's having met the generally accepted standards of practice during the supervised practice.
3. Clinical Supervision.
and (iii) A written attestation statement of the proposed non- LCSW supervisor’s alignment with the Social Work Code of Ethics.
4. Number of hours of post-degree experience practicing social work under supervision.
5. Number of hours of post-degree supervision.
C. Examination. In accordance with sections 12-245-204(4)(b), 12-245-404(1)(c), 12-245-404(2)(d), C.R.S., the Board establishes these requirements for the licensing examination to demonstrate professional competence in social work. The Board shall admit applicants to the examination once the educational requirements have been met.
1. Jurisprudence Examination. Applicants shall be required to pass a Board developed jurisprudence examination.
2. National Examination. Social work applicants shall take the appropriate examination required for the level of licensure sought, and as approved by the Board.
3. Application. An applicant for licensure shall apply directly to the testing service the Board may contract with at the time, to sit for the appropriate examination.
4. Exam Results. Pass/fail examination results will be valid for up to five years after the date of the examination. An applicant who holds a current license in Colorado as a licensed social worker (LSW) may be exempt from this provision, if at the time of submitting an Application for Upgrade from LSW to licensed clinical social worker (LCSW), the applicant has a current, active license in good standing in Colorado as an LSW, and has taken and passed the appropriate examination required for an LCSW.
1.15 MILITARY EDUCATION, TRAINING, AND EXPERIENCE (C.R.S. § 12-20-202(4))
Education, training, or service gained in military services outlined in section 12-20-202(4), C.R.S., to be accepted and applied towards receiving a license, must be substantially equivalent, as determined by the Board, to the qualifications otherwise applicable at the time of receipt of application. It is the applicant's responsibility to provide timely and complete evidence for review and consideration. Satisfactory evidence of such education, training, or service will be assessed on a case by case basis.
1.16 RECORDS REQUIRED TO BE KEPT AND RECORD RETENTION (C.R.S. §§ 12-245-204(4),
12-245-224(1)(u))
A. General. Except as provided in subsection (G) of this Rule, every social worker shall create and shall maintain records on each of their social work/psychotherapy clients. Every social worker shall retain a record, as defined in subsection (B) of this Rule, on each social work/psychotherapy client for a period of seven years, commencing on the termination of social work/psychotherapy services or on the date of last contact with the client, whichever is later.
B. Record. Every social worker shall create and shall maintain a record for each social work/psychotherapy client. Every social worker shall retain a record on each social work/psychotherapy client for a period of seven years. A record shall contain, as applicable to the mental health services rendered, at least the following information:
1. Name of treating therapist.
2. Client's identifying data to include name, address, telephone number, gender, date of birth, and if applicable the name of the parent or guardian. If the client is an organization, the name of the organization, telephone number and name of the principal authorizing the mental health provider's services or treatment;
3. Reason(s) for the psychotherapy services;
4. Mandatory disclosure statement.
5. Dates of service including, but not limited to the date of each contact with client, the date on which services began, and the date of last contact with client;
6. Types of service;
7. Fees;
8. Any release of information;
9. The records must be prepared in a manner that allows any subsequent provider to reasonably conclude what occurred;
10. Name of any test administered, each date on which the test was administered, and the name(s) of the person(s) administering the test;
11. Information on each referral made to and each consultation with another social worker or other health care provider. This information shall include the date of the referral or consultation, the name of the person to whom the client was referred, the name of the person with whom consultation was sought, the outcome (if known) of the referral, and the outcome (if known) of the consultation;
12. A final closing statement (if services are over), if applicable.
D. Record Storage. Every social worker shall keep and store client records in a secure place and in a manner that both assures that only authorized persons have access to the records and protects the confidentiality of the records and of the information contained in the records.
E. Transfer of Records. Whenever a social worker deems it necessary to transfer their client records to another social worker or other health care provider, the social worker making the transfer shall obtain the client's consent to the transfer (where possible).
F. Disposition of Records. If the social worker is not available to handle their own records, the social worker and/or their estate shall designate an appropriate person to handle the disposition of records. The social worker or the estate designated representative shall make a reasonable effort to notify the primary client(s) of the disposition. A plan for the disposition of records shall be in place for all social workers for the following conditions:
1. Disability, illness, or death of the social worker;
2. Termination of social worker's practice; and 3. Sale or transfer of practice.
G. Record Destruction. Every social worker shall dispose of client records in a manner or by a process that destroys or obliterates all client identifying data. However records cannot be destroyed until after seven years or as otherwise provided in these Rules or any other applicable statute.
H. Record keeping in agency/institutional settings. A social worker need not create and maintain separate client records if the social worker practices in an agency or institutional setting and the social worker:
1. Sees the client in the usual course of that practice;
2. Keeps client records as required by the agency or institution; and 3. The agency or institution maintains client records.
1.17 RELIGIOUS MINISTRY EXEMPTION
A. Whenever exemption from the Board's jurisdiction is claimed based on an assertion of the practice of religious ministry as stated in section 12-245-217(1), C.R.S., the Board shall consider factors, including but not limited to those listed below, which, taken together and placed within the context of the incident in question, would tend to reasonably indicate that the person seeking the exemption was engaged in the practice of religious ministry. Before taking action on a complaint, the Board shall consider the following factors and other information that indicates the person claiming exemption was not engaged in the practice of religious ministry at the time of the alleged violation of the statute. If the Board determines that this exemption applies, and the Licensee was practicing religious ministry, The Board will have no jurisdiction to take any further action on the complaint.
B. In determining whether the practice of psychotherapy has occurred, the Board analyzes activities and the basic nature of the interaction among the persons involved. The analysis focuses on what occurred, on how it occurred, and on why it occurred.
C. Factors.
1. Whether the client or guardian had received notice or reasonably understood that the therapy in question was a part of religious practice/ministry.
2. Whether the client or guardian was seeking therapy from a religious organization to which the complainant belonged at any time.
3. Whether a written agreement or disclosure existed that stated that the therapy in question was part of religious practice/belief.
4. Whether the therapy services were conducted in a house of worship or on property belonging to a religious organization.
5. Whether the provider of the therapy normally represents themselves as a religious official who is counseling as part of a religious ministry.
6. Whether the therapy services were part of an on-going relationship, formed because the provider is a spiritual counselor to the client.
7. Whether the provider of psychotherapy services holds a position of trust within a religious organization.
8. Whether the provider of the therapy services advertise psychotherapy services to the general public for a fee.
9. Whether the provider of the therapy services collects fees or expects/requires donations, offerings, tithes, etc.
10. Whether the therapy services provided are based on any religious orientation or viewpoint.
11. Whether the provider engaged in the practice of therapy services accountable or subject to any religious organization or person for misdeeds or acts of misconduct.
12. Whether the provider of therapy services is a member of a religious organization recognized by the Internal Revenue Service. Does the organization hold 501(C)(3) tax- exempt status? 13. Whether the provider of therapy services is trained in theology or any other field, area, or specialty related to the study of a religious or spiritual orientation.
14. Whether the service was provided is within a private practice setting.
15. Whether the provider of the therapy services has a declaration of religious mission or a statement identifying the religious views or beliefs of the organization or person.
1.18 CONTINUING PROFESSIONAL COMPETENCE (C.R.S. § 12-245-410)
Pursuant to section 12-245-410, C.R.S., effective January 1, 2011, licensed social workers and licensed clinical social workers shall demonstrate continuing professional competence through participation and compliance with the Continuing Professional Development program in order to renew, reinstate or reactivate a license to practice social work in the state of Colorado.
A. Definitions.
1. Continuing Professional Competence. Continuing Professional Competence (CPC) means the ongoing ability of a licensed social worker or licensed clinical social worker to learn, integrate and apply the knowledge, skill, and judgment to practice according to generally accepted industry standards and professional ethical standards in a designated role and setting.
2. Continuing Professional Development. Continuing Professional Development (CPD) is the program through which a licensed social worker or licensed clinical social worker satisfies the Continuing Professional Competence requirements set forth in section 12- 245-410, C.R.S., to renew, reinstate or reactivate a license.
3. Continuing Professional Development Portfolio. The Continuing Professional Development Portfolio (CPD Portfolio) is an instructional guide and workbook for the CPD program.
4. Professional Development Hours. Professional Development Hours (PDH) are the units of measurement of active learning used to accrue credit in the CPD program. PDH are equivalent to clock hours.
5. Professional Development Activities. Professional Development Activities (PDA) are Board approved learning activities undertaken for the purpose of Continuing Professional Development.
6. Professional Practice Rubric. The Professional Practice Rubric (“Rubric”) is a reflective practice tool that identifies the foundational knowledge areas of the profession as well as three levels of practice and skill advancement.
7. Personal Learning Plan. The Personal Learning Plan (“Learning Plan”) is a document used to plan and record learning for each cycle in the CPD program.
B. Requirements.
1. Licensed social workers and licensed clinical social workers shall demonstrate continuing professional competence through participation and compliance with the Continuing Professional Development program in order to renew, reinstate or reactivate a license to practice social work in the state of Colorado.
2. Licensed social workers and licensed clinical social workers must complete the following requirements in accordance with the current CPD Portfolio:
C. Professional Practice Rubric. The Professional Practice Rubric should be completed prior to renewing, reinstating or reactivating a license.
D. Learning Plan. Licensees shall draft a Personal Learning Plan based upon the Professional Practice Rubric. The Learning Plan shall consist of PDA as set forth in Board Rule 1.18(F). Licensees shall execute their Learning Plan by completing all PDA and PDH before the date upon which they renew their license. Changes to the Learning Plan shall not be allowed after renewing, reinstating or reactivating a license.
E. Professional Development Hours. Licensed social workers and licensed clinical social workers shall complete forty PDH each renewal cycle in order to renew their license or certification.
1. Licensees shall document their completion of their PDA and PDH according to the guidelines set forth in the current CPD Portfolio. Licensees should be prepared to submit documentation of their CPD compliance upon request by the Board.
2. Course work provided by an accredited educational institution or a nationally or regionally recognized professional organization as a single Professional Development Activity may be credited hour for hour for up to the full 40 hour PDH requirement each renewal cycle.
3. Other than course work as defined in section E(2) of this rule, no more than twenty PDH in a single Professional Development Activity shall be credited and recognized each renewal cycle.
4. Licensees receiving an original, reinstated or reactivated license, during the renewal cycle must accrue one point sixty six (1.66) PDH for each month or portion thereof they are licensed during the current renewal cycle.
5. A maximum of five PDH may be carried from the last renewal cycle to the next renewal cycle if the PDH were earned within six months of license expiration and are in excess of the forty PDH required for the current renewal cycle.
6. Licensees shall retain documentation of their CPD compliance for a minimum of five years from the license expiration date for the renewal cycle during which PDH were accrued.
F. Professional Development Activities. To qualify for PDH credit, Licensees must select PDA that are allowed by the Board.
1. The Board allows the following PDA:
2. Professional Development Activities develop your professional skill and must be directly relevant to your competence in the social work field. PDAs provide new knowledge, skills or attitudes and sharpen or expand existing skills.
3. It is within the discretion of the Board to deny credit for any PDH that does not meet the criteria set forth in the current CPD Portfolio or the definition of Continuing Professional Competence contained in section 12-245-410(3), C.R.S.
4. Unacceptable Professional Development Activities. The following types of activities are ineligible for credit: Serving on a federal, state or municipal board or commission.
G. Deem Status.
1. To be eligible for Deem Status pursuant to section 12-245-410(1)(c), C.R.S., a State Department CPC program must satisfy the definition of Continuing Professional Competence pursuant to section 12-245-410(3), C.R.S. Employees and contractors of qualifying programs in State Departments shall be deemed to have met the CPC requirements.
2. Licensees deemed to have met the CPC requirements are subject to an audit. The audit shall review the program for which the Licensee has justified their Deem Status to ensure that it meets the definition of CPC outlined in section 12-245-410(3), C.R.S., and shall verify the Licensee's successful completion of the program.
3. Licensees found to have falsified their Deem Status or who attested their fulfillment of CPC requirements for an unqualified State Department program, are subject to discipline by the Board.
H. Exemptions.
1. Military Active Duty. Licensees may be exempt from licensing requirements as provided in section 12-20-302, C.R.S., including but not limited to, military personnel who have been called to federally funded active duty for more than 120 days for the purpose of serving in a war, emergency, or contingency from the payment of any professional or occupational license, certification or registration fees, including renewal fees, and from continuing professional competency requirements for a renewal cycle that falls within the period of service or within the six months following the completion of service in the war, emergency or contingency.
2. Dual Licensure. The Board may grant an exemption from the CPD requirement if the licensed social worker or licensed clinical social worker has fulfilled the CPD requirements set forth in: sections 12-245-506, 12-245-606, or 12-245-806, C.R.S.
1.19 INACTIVE LICENSE STATUS AND REACTIVATION OF LICENSE
A. Inactive status. Pursuant to section 12-20-203, C.R.S., any Licensee may apply to the Board to be transferred to an inactive status. Such application shall be in the form and manner designated by the Board. The holder of an inactive license shall not be required to comply with the continuing competency requirements for renewal so long as he or she remains inactive.
1. During such time as a Licensee remains in an inactive status, he or she shall not perform those acts restricted to active licensure pursuant to section 12-245-405, C.R.S. The Board shall retain jurisdiction over inactive licensees for the purposes of disciplinary action pursuant to section 12-245-222(1)(d), C.R.S.
2. Practicing with an inactive license shall constitute unlicensed practice and, therefore, may be grounds for disciplinary or injunctive action, up to and including revocation.
B. Reactivation requirements. To be considered for license reactivation, an applicant must submit a completed reactivation application and the reactivation fee.
C. Required statements.
1. Each applicant for reactivation shall certify the following:
2. The Board may decline to issue a license to an applicant for reactivation if disciplinary action is pending or if there is an unresolved complaint.
D. Continuing Professional Competence. Pursuant to section 12-245-410, C.R.S., effective January 1, 2011, licensed social workers or licensed clinical social workers shall demonstrate continuing professional competence in order to reactivate.
1. An applicant for reactivation must comply with all Continuing Professional Development reactivation requirements pursuant to Board Rule 1.18 having completed forty Professional Development Hours within the two years immediately preceding the application receipt date.
E. Additional criteria for a license inactive more than two years. The Board has established the following criteria for determining whether an applicant for reactivation has demonstrated competency to practice as required by section 12-245-205(3), C.R.S.
1. An applicant whose license has been inactive more than two years shall pass a Board approved jurisprudence examination and either:
1.20 IMPOSITION OF ADMINISTRATIVE FINES (C.R.S. § 12-245-225(2))
A. Fines; Non-Exclusive Sanction. The Board, in its discretion, may impose a fine or fines in lieu of, or in addition to, any other disciplinary sanction. The term “social worker” as contemplated under section 12-245-225(2), C.R.S., and this Rule shall include any person who has been licensed at any applicable time under the Mental Health Practice Act to practice social work, including a “licensed social worker” under section 12-245-405(1), C.R.S., and a “licensed clinical social worker” under section 12-245-405(2), C.R.S. Accordingly, liability for administrative fines may extend to any such person 1. Holding a current license; or 2. Holding or having the status of a revoked, suspended or expired license; at the time of the violation.
B. Fine for Each Violation. Pursuant to section 12-245-225(2), C.R.S., provides authority for the Board to impose an administrative fine against a social worker for a violation of an administrative requirement. The Board, in its discretion, may impose a separate fine for each violation and shall consider the nature and seriousness of the violation prior to imposing any fine.
C. Fines: Schedule of Fines. The Board may so impose a fine or fines consistent with the following Schedule:
1. For a social worker's first violation, a fine of no more than $1,000.
2. For a social worker's second violation, a fine of no more than $2,500.
3. For a social worker's third and any additional or subsequent violations, a fine of no more than $5,000.
In a disciplinary proceeding, in which fines are sought to be imposed, the Board in determining the number of violations for purposes of application of the above schedule, the Board may count as a violation, each prior violation adjudicated against the social worker.
D. Payment of Fines.
1. Fine Amount; When Due. A total fine amount of five hundred dollars ($500) or less imposed by the Board must be paid in full, including the applicable surcharge, at the time the Final Agency Order is entered or a Stipulation is reached between the parties. A total fine amount greater than five hundred dollars ($500) imposed by the Board must be paid in full, including the applicable surcharge, in accordance with the time frame set forth in the Final Agency Order or Stipulation.
2. Delinquent Payment Consequences. A social worker who fails to pay a fine imposed under this Rule when due as defined above or pursuant to a Final Agency Order or Stipulation may be subject to further discipline, including suspension or revocation of their license to practice. Section 12-245-224(1)(b), C.R.S., provides that violation of an order of the Board is a “Prohibited Activity.”
E. Compliance with Law. Payment of a fine does not exempt the social worker from continuing compliance with the Mental Health Practice Act or any Orders of the Board.
1.21 CONFIDENTIAL AGREEMENTS TO LIMIT PRACTICE FOR PHYSICAL OR MENTAL ILLNESS
(C.R.S. § 12-245-223)
A. Notice to Board. No later than thirty days from the date a physical or mental illness or condition impacts a social worker's ability to perform professional services with reasonable skill and safety, the social worker shall provide the Board, in writing, the following information:
1. The diagnosis and a description of the illness or condition;
2. The date that the illness or condition was first diagnosed;
3. The name of the current treatment provider and documentation from the current treatment provider confirming the diagnosis, date of onset, and treatment plan;
4. A description of the social worker's practice and any modifications, limitations or restrictions to that practice that have been made as a result of the illness or condition;
5. Whether the social worker has been evaluated by, or is currently receiving services from the Board's authorized Peer Health Assistance Program related to the illness or condition and, if so, the date of initial contact and whether services are ongoing.
B. Change of Circumstances; Further Notice. The social worker shall further notify the Board of any significant change in the illness or condition (“change of condition”) that impacts the social worker's ability to perform a professional service with reasonable skill and safety. The social worker must notify the Board of a positive or negative change of condition. Such notification shall occur within thirty days of the change of condition. The social worker shall provide the Board, in writing, the following information:
1. The date of the change of condition;
2. The name of the current treatment provider and documentation from the current treatment provider confirming the change of condition, the date that the condition changed, the nature of the change of condition, and the current treatment plan;
3. A description of the social worker's practice and any modifications, limitations or restrictions to that practice that have been made as a result of the change of condition;
4. Whether the social worker has been evaluated by, or is currently receiving services from, the Peer Health Assistance Program related to the change of condition and, if so, the date of initial contact and whether services are ongoing.
C. Confidential Agreement; Board Discretion. Compliance with this Rule is a prerequisite for eligibility to enter into a Confidential Agreement with the Board pursuant to section 12-245-223, C.R.S. However, mere compliance with this Rule does not require the Board to negotiate regarding, or enter into, a Confidential Agreement. Rather, the Board will evaluate all facts and circumstances to determine if a Confidential Agreement is appropriate.
D. Failure to Notify. If the Board discovers that a social worker has a mental or physical illness or condition that impacts the social worker's ability to perform a professional service with reasonable skill and safety and the social worker has not notified the Board of such illness or condition as required under (Section for Notice to Board), the social worker shall not be eligible for a Confidential Agreement and may be subject to disciplinary action for failure to notify under section 12-245-223(1), C.R.S., and other related violations contemplated under section 12-245-224(1)(f), C.R.S.
1.22 STUDENTS ENROLLED IN A COUNCIL ON SOCIAL WORK EDUCATION (CSWE)
ACCREDITED OR CANDIDACY PROGRAM AND PRACTICING AS PART OF A SCHOOL PRACTICUM OR CLINICAL PROGRAM (§ 12-245-217(2)(g C.R.S.) A. Pursuant to section 12-245-217(2)(g), C.R.S., students enrolled in a CSWE accredited or CSWE candidacy program and practicing as part of the school practicum or clinical program are exempt from licensure requirements.
B. Practicing as part of CSWE accredited or CSWE candidacy program or clinical program includes continued practice between school terms up to date of conferral of degree as necessary for continuity of care.
1.23 REQUIRED DISCLOSURE TO PATIENTS - CONVICTION OF OR DISCIPLINE BASED ON
SEXUAL MISCONDUCT (§ 12-30-115, C.R.S.)
A. On or after March 1, 2021, a licensee, as defined in Rule 1.1 (F), 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 licensee’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 A to these rules.
1. The patient must, through their signature on the disclosure form, acknowledge the receipt of the disclosure and agree to treatment with the licensee.
2. This disclosure shall be separate and apart from the mandatory disclosure required pursuant to section 12-245-216, C.R.S.
C. Timing of Disclosure: This disclosure shall be provided to a patient the same day the patient schedules a professional services appointment with the licensee. If an appointment is scheduled the same day that services will be provided, or if an appointment is not required, the disclosure must be provided in advance of the treatment.
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 schedules follow-up treatment appointments.
2. For treatment series or follow-up treatment appointments, one disclosure prior to the first appointment is sufficient, unless the information the licensee 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 licensee 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 licensee’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. 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 acknowledgement;
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. A 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.
1.24 Clinical Social Worker Candidate Registration (§ 12-245-404(4), C.R.S.)
A. Registration as a clinical social worker candidate as set forth in section 12-245-404(4), C.R.S, requires the candidate demonstrate completion of a master's or doctorate degree from a graduate school of social work.
1. For the purpose of registration as a clinical social work candidate, “graduate school of social work” includes a social work program or a doctoral social work education program approved or accredited by the CSWE; or a CSWE candidacy program.
1.25 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 pursuant to sections 12-20-204, 12-30-112, and 12-245-204(4)(a), C.R.S., in consultation with the Commissioner of Insurance and the State Board of Health. The purpose of this rule is to establish requirements for health care providers to provide disclosures to covered persons who are utilizing a health benefit plan about the potential of balance billing when receiving post-stabilization services or covered non-emergency services from an out-of-network provider at an in-network facility. This rule applies to health care providers. Balance billing by a health care provider is only permitted when the criteria established in Colorado law, including but not limited to sections 12-30-112 and 12-30-113, C.R.S., are met.
A. Definitions, for purposes of this rule, are as follows:
1. “Ancillary Services” as defined in section 12-30-112(1)(a), C.R.S.
2. “Balance Bill” and “Balance Billing” as defined in section 10-16-704(19)(c), C.R.S.
3. “Covered Non-emergency Services” means services that are not emergency services as defined in section 10-16-704(19)(e), C.R.S., are services covered by a covered person’s health benefit plan, and are not ancillary services as defined in section 12-30-112(1)(a), C.R.S.
4. “Covered Person” as defined by section 10-16-102(15), C.R.S.
5. “Health Benefit Plan” as defined by section 10-16-102(32), C.R.S.
6. “Health Care Provider” means “provider,” as defined in section 10-16-102(56), C.R.S.
7. “In-Network Facility” means a facility, either within or outside of Colorado, that, under a contract with a carrier or with its contractor or subcontractor, has agreed to provide health-care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly, from the carrier.
8. “Out-of-Network Provider” means a Health Care Provider who is not a “Participating Provider.”
9. “Participating Provider” as defined in section 10-16-102(46), C.R.S.
10. “Post-Stabilization Services” means covered services related to an emergency medical condition, as defined in section 10-16-704(19)(d), C.R.S., that are provided once the criteria set forth in section 10-16-704(19)(e)(III) are met.
B. Disclosure requirements.
1. An Out-of-Network Provider may balance bill a Covered Person for (a) Post-Stabilization Services in accordance with section 10-16-704, C.R.S., and (b) Covered Non-Emergency Services provided in an In-Network Facility that are not Ancillary Services, but only if the Out-of-Network Provider meets the requirements set forth in section 12-30-112(3.5), C.R.S.
2. If a Covered Person may incur a claim for Post-Stabilization Services or Covered Non- Emergency Services from an Out-of-Network Provider, the Out-of-Network Provider shall complete and provide the notice contained in Appendix B of these rules or a similar disclosure which complies with the requirements set forth in section 12-30-112(3.5), C.R.S.
3. Such notice must be provided in the 15 most common languages in Colorado, which, for purposes of this regulation, are English, Spanish, Vietnamese, Chinese, Korean, Russian, Amharic, Arabic, German, French, Nepali, Tagalog, Japanese, Cushite, Persian.
C. If applicable and in addition to their responsibilities under this Rule, Health Care Providers shall also comply with the “No Surprises Act,” 42 U.S.C.A. § 300gg-111, Pub.L 116-260, as amended.
D. Noncompliance with this Rule may result in the imposition of any of discipline made available by section 12-245-224(1)(b), C.R.S.
APPENDIX A 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 section 12-30-115, C.R.S., and Rule 1.23. 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 section 12-30-115, C.R.S., you may to include additional information that specifically applies to your situation and practice.
A. Licensee, as defined in Rule 1.1F, 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 licensee shall provide, at a minimum:
1. The date that the final judgment of conviction or guilty plea was entered;
2. The nature of the offense or conduct that led to the final conviction or guilty plea;
3. The type, scope, and duration of the sentence or other penalty imposed, including whether:
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 licensee’s ability to practice if the final agency action is based in whole or in part on:
1. a conviction for or a guilty plea to a sex offense, as defined in § 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 § 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. The type, scope, and duration of the agency action imposed, including whether:
2. The nature of the offense or conduct, including the grounds for probation or practice limitations specified in the final agency action;
3. The date the final agency action was issued 4. The date the probation status or practice limitation ends; and 5. The contact information for the professional regulatory board or agency that imposed the final agency action on the licensee, 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 Patient Name ______________________________________________________________ Patient or Responsible Party’s Signature Date If signed by Responsible Party (parent, legal guardian, or custodian), print Responsible Party’s name and relationship to patient:
_______________________________________________________________ Print Responsible Party Name Print Relationship to Patient _______________________________________________________________ Provider Signature Date APPENDIX B BALANCE BILLING NOTICE PATIENT RIGHTS INFORMATION Check the appropriate box:
☐ Your provider is proposing to use an out-of-network care provider in delivering your health care service(s). This facility is in-network with your insurance but there may be care providers involved in your care that are out-of-network. ☐ Your provider is proposing to deliver post-stabilization care at an out-of-network facility. You have received emergency services at the out-of-network facility and are now stabilized, but you may require additional health care services. You are not required to consent to receive these services from the out-of-network care provider or continue to receive post-stabilization care at an out-of-network facility. If you choose to proceed with the proposed out-of-network care provider or facility you may be billed for costs detailed in the Good Faith Estimate below. The additional costs you pay may not accrue toward insurance cost sharing or deductibles.
You may choose to use an in-network provider from the list below or you may choose to transfer your care to an in-network facility for post-stabilization services. If you choose to proceed with an in-network provider or transfer to an in-network facility, the cost will not exceed the amount allowed by your insurance plan.
You chose to receive this Notice ☐ electronically or ☐ in paper form. This notice must have been provided to you, either in paper or electronically, per your preference within the following timeframes:
1. At least seventy-two hours in advance of the date of services, if the appointment was scheduled at least seventy-two hours in advance;
2. At least three hours before the scheduled appointment, if the appointment was made less than seventy-two hours in advance.
This is not a contract for services. Your provider is required to retain this form for seven years. This form must be available to you in the 15 languages most common to the geographic region where your provider is located, which include English, Spanish, Vietnamese, Chinese, Korean, Russian, Amharic, Arabic, German, French, Nepali, Tagalog, Japanese, Cushite, and Persian. BILLING ADVISEMENT (choose applicable billing scenario)
☐ Out-of-Network Provider at In-Network Facility Your provider is proposing to use an out-of-network care provider in delivering your service(s). That out- of-network provider is/are:
[PROVIDER NAME] Description of service(s) to be provided by an in-network facility by an out-of-network provider: [SERVICE] You scheduled the service(s) on [DATE] at [TIME]. You are planning to receive the service(s) stated above on [DATE] at [TIME] Do you need prior authorization from your insurance company for the service(s) provided at this facility? [Y / N] Good Faith Estimate for the total cost of the service(s) to you, the patient: [$] Does this facility employ in-network care providers who provide the service(s) detailed above? [Y / N] If Yes, the in-network care provider(s) who provide the service(s) are: [PROVIDER NAME] NOTE: If there is no in-network provider to provide the service(s) at this in-network facility you cannot be balanced billed for the services provided by the out-of-network provider. OR ☐ Post-Stabilization Services Your provider is proposing to deliver post-stabilization care at an out-of-network facility. The out-of- network facility is and/or the provider(s) is/are:
[FACILITY/PROVIDER NAME] Description of post-stabilization service(s) to be provided by an out-of-network facility or provider: [SERVICE] You scheduled the service(s) on [DATE] at [TIME]. You are planning to receive the service(s) stated above on [DATE] at [TIME].
Good Faith Estimate for the total cost of the service(s) to you, the patient: [$] I [PATIENT NAME] received this form at [TIME] on [DATE]. ___________________________________________ SIGNATURE OF PATIENT [TIME] and [DATE] _________________________________________________________________________ Editor's Notes History Rule 17(c) eff. 12/01/2009.
Rule 17(d)(4) eff. 02/03/2010.
Purpose and Scope, Rules 12, 15, 19, 20 emer. rules eff. 01/01/2011. Purpose and Scope, Rules 12, 15, 19, 20 eff. 02/01/2011. Entire rule emer. rule eff. 12/06/2011.
Entire rule eff. 02/01/2012.
Rule 12 eff. 03/16/2016.
Rule 12 eff. 01/14/2017.
Entire rule eff. 11/14/2020.
Rules 1.6 A, 1.12 C-D, 1.23, Appendix A eff. 05/15/2021. Rule 1.8 B eff. 11/14/2021.
Rules 1.26, 1.27 emer. rules eff. 09/16/2022.
Rules 1.12 C, 1.25-1.27, Appendix B eff. 11/14/2022.
Rules 1.26, 1.27 repealed eff. 01/14/2024.
Rules 1.25, Appendix B eff. 08/30/2025.
Annotations Rules 1.27 B. and 1.27 C. (adopted 09/16/2022) were not extended by Senate Bill 23-102 and therefore expired 05/15/2023.