DEPARTMENT OF REGULATORY AGENCIES AUDIOLOGY RULES AND REGULATIONS 3 CCR 711-2 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ AUTHORITY Basis: These rules are promulgated and adopted by the Director of the Division of Professions and Occupations pursuant to section 12-210-109(4), C.R.S.

Purpose These rules are adopted by the Director in order to clarify statutory requirements pursuant to Article 210 of Title 12.

1.1 Original Licensure

The purpose of this Rule is to clarify the requirements for licensure pursuant to section 12-210-105, C.R.S.

A. To qualify for licensure as an audiologist a person must have:

1. 1. Earned a doctoral degree in audiology from a program, that is or, at the time the applicant was enrolled and graduated, was offered by an institution of higher education or postsecondary education accredited by:
   1. a. The Council on Academic Accreditation (CAA) within the American Speech- Language-Hearing Association (ASHA), or b. The Accreditation Commission for Audiology Education (ACAE), which is recognized by the Council for Higher Education Accreditation (CHEA) and approved by the Director; or
2. 2. Earned a master’s degree from program with a concentration in audiology that was conferred before July 1, 2007, from a program of higher learning that is or, the time the applicant was enrolled and graduated, was offered by an institution of higher education or postsecondary education accredited by the CAA within ASHA, or another program approved by the Director; and
   1. a. Obtained a certificate of clinical competency in audiology from the American Speech-Language-Hearing Association (ASHA).

1.2 Licensure by Endorsement

The purpose of this Rule is to clarify licensure by endorsement requirements pursuant to section 12-20- 202(3), C.R.S.

A. To qualify for licensure by endorsement an applicant must:

1. 1. Possess an active license in good standing to practice audiology in another state or United States territory, through the federal government, or hold a military occupational specialty, as defined in section 24-4-201, C.R.S.; and 2. Present satisfactory proof to the Director:
   1. a. That the active license in good standing issued required qualifications substantially equivalent to the qualifications for original licensure in Colorado, or b. That the applicant has held for at least one year an active license in good standing in a jurisdiction with a scope of practice that is substantially similar to the scope of practice for audiology pursuant to section 12-210-102(3), C.R.S.

B. Substantially equivalent experience and credentials may be determined by the Director and may include the following:

1. 1. Earned a doctoral degree in audiology from a program, that is or, at the time the applicant was enrolled and graduated, was offered by an institution of higher education or postsecondary education accredited by:
   1. a. The Council on Academic Accreditation (CAA) within the American Speech- Language-Hearing Association (ASHA), or b. The Accreditation Commission for Audiology Education (ACAE), which is recognized by the Council for Higher Education Accreditation (CHEA) and approved by the Director.
2. 2. In the alternative, substantially equivalent experience and credentials may include:
   1. a. Earned a master’s degree from a program with a concentration in audiology, and b. Passed an acceptable entry-level examination or obtained a Certificate of Clinical Competence from in audiology from ASHA. .

C. The Director may consider substituting either:

1. 1. Five years of active practice in good standing as an audiologist, completed within the eight years prior to the date of application, in place of section (B)(2)(a) above, or 2. Documentation of 1,820 hours of active practice in good standing as an audiologist, completed within the three years prior to the date of application in place of the acceptable entry-level examination or obtained certificate of competency in audiology in section (B)(2)(b) of this Rule.

D. The practice of audiology as part of military service, including a clinical audiology externship, shall be credited towards the requirements of active practice of section (C) of this Rule.

1.3 Requirements for Reinstatement or Reactivation

The purpose of this Rule is to clarify the requirements for reinstatement of an audiologist license that has expired pursuant to sections 12-20-202(2) and 12-210-106, C.R.S., or reactivation of an inactive audiologist license pursuant to section 12-20-203, C.R.S.

A. A licensee applying for reinstatement or reactivation of an expired or inactive license shall complete a reinstatement or reactivation application, pay a fee, and attest to the appropriate malpractice/professional liability insurance coverage as required by Rule 1.5.

B. If the license has been expired or inactive for more than two years from the date of receipt of the reinstatement or reactivation application, a licensee applying for reinstatement of an expired or reactivation of an inactive license shall establish “competency to practice” under sections 12-20- 202(2)(c)(II)(A) and (D), and 12-20-105, C.R.S., as follows:

1. 1. Verification of licensure in good standing from another state along with verification of active practice in that state for two years of the previous five years from the date of application for reinstatement or reactivation;
2. 2. Completion of thirty hours of continuing education courses related to the practice of audiology during the two years immediately preceding the application for reinstatement or reactivation. The continuing education must meet the approval of the Director;
3. 3. Supervised practice for a period of no less than six months subject to the terms established by the Director; or 4. By any other means approved by the Director.

C. An applicant who is expired or inactive for more than five years must meet the requirements of Rule 1.1.

1.4 Patient Medical Records

The purpose of this Rule is to clarify the requirements for maintaining patient medical records pursuant to section 12-210-114, C.R.S., by a licensed audiologist (licensee).

A. Each licensee shall develop a written plan to ensure the security of patient records pursuant to section 12-210-114, C.R.S., and must address at least the following:

1. 1. The storage and proper disposal of patient medical records;
2. 2. The disposition of patient medical records in the event the licensee dies, retires, or otherwise ceases to practice or provide audiology services to patients; and 3. The method by which patients may access or obtain their medical records promptly if any of the events described in paragraph (2) above of this Rule occurs.

B. The licensee or licensee’s supervisor or licensee designated by licensee’s employer shall maintain all medical records for at least seven years. These records shall identify the patient’s name, the goods and services provided to each patient (excluding minor accessories and batteries), and the date and price of each transaction.

1.5 Malpractice Coverage/Professional Liability Insurance

The purpose of the following Rule is to clarify the amount of malpractice coverage/professional liability insurance that must be maintained by an audiologist who provides services to patients as required by sections 12-210-105(4)(e), 12-210-109(3), and 12-210-111, C.R.S.

A. For purposes of this Rule, malpractice coverage pursuant to section 12-210-109(3), C.R.S., and professional liability insurance pursuant to sections 12-210-105(4)(e) and 12-210-111, C.R.S., are synonymous and the same requirement.

B. An audiologist shall maintain malpractice coverage/professional liability insurance of at least $1,000,000 per incident and $3,000,000 aggregate per year.

1.6 Written Disclosures to Purchasers

The purpose of this Rule is to clarify the type of written disclosures to be provided to purchasers of hearing aids pursuant to sections 12-210-109(4), 12-210-202(1)(e), and 6-1-701(1)(c)(I)(A), C.R.S., that will protect such purchasers and that are necessary for the enforcement and administration of Article 210 of Title 12.

A. Licensees shall identify themselves by listing their name, license type (i.e., audiologist), license number, business address and telephone number on every contract or purchase agreement for the sale of a hearing aid.

B. Licensees shall include provisions on all contracts and purchase agreements stating the following:

1. 1. Audiologists are regulated by the Division of Professions and Occupations.
2. 2. Any complaints can be filed against the licensee with the Office of Audiology Licensure within the Division of Professions and Occupations.
3. 3. The Office of Audiology Licensure’s website, address, and telephone number.
4. 4. An apprentice is not permitted to sell hearing aids independently of the supervising licensed hearing aid provider.
5. 5. Notice of thirty-day rescission period in accordance with section 12-210-202(1)(e), C.R.S.

C. If any part of the purchase price of a hearing aid, including any fees for services, is to be non- refundable, the following disclosures of all non-refundable charges are required on the contract or purchase agreement and must be clearly stated as non-refundable:

1. 1. A separate line item clearly stated as non-refundable, the total cost of all non-refundable charges related to the purchase of the hearing aids that are not included in the purchase price of the hearing aids such as: fitting and consultation fees, rehabilitation services, and/or non-refundable parts, attachments, or accessories that are disposable, one-time use, or similar products of low cost, e.g. batteries and cords.
2. 2. A provision that clearly identifies all professional services including, but not limited to, those listed in paragraph (1) above, and the exact charge for each service.

1.7 Hearing Aid Provider Trainees/Apprentices

The purpose of this Rule is to clarify the transition of a trainee license type, establish the time period during which an apprentice license shall be valid, and to specify the components of the training required to be completed by apprentices pursuant to sections 12-210-102(3)(b), 12-210-108(2)(l), 12-230- 201(3)(b)(I), C.R.S.

A. Unlicensed Trainees

1. 1. As of July 1, 2013, no new trainee licenses will be issued. Trainee licenses that were issued prior to that date expired on June 30, 2013.
2. 2. An unlicensed person in this state training to be a licensed hearing aid provider after June 30, 2013, and prior to June 1, 2014, may do so under the direct, line-of-sight supervision of a licensed audiologist. However, such person is not permitted to sell hearing aids independently of the supervising audiologist, and cannot conduct hearing tests or perform the initial fitting of hearing aids.

B. Licensed Apprentices

1. 1. On or after June 1, 2014, a person in this state training to be a licensed hearing aid provider must possess a valid apprentice license issued by the Director. Any work prior to the issuance of an apprentice license will not apply as training hours towards the apprentice license status.
   1. a. The supervising audiologist retains ultimate responsibility for the care provided by the apprentice and is subject to disciplinary action by the Director for failing to adequately supervise a trainee, pursuant to section 12-210-108(2)(l), C.R.S.
   2. b. An apprentice is not permitted to sell hearing aids independently of the supervising audiologist.
2. 2. In order to be eligible for an apprentice license to be issued by the Director, an applicant must submit verification of training to become a licensed hearing aid provider, which training shall meet the requirements of paragraph (3) below, and will be provided under the direct supervision of an identified licensed audiologist whose license is active and in good standing.
3. 3. Once licensed to begin training, an apprentice is required to complete at least the first six months of training under direct supervision, including a minimum of 300 documented hours of on-site supervised training in the following areas:
   1. a. Taking a case history and review;
   2. b. Otoscopy;
   3. c. Testing of hearing including air conduction and bone conduction with proper masking when needed;
   4. d. Testing of speech including speech recognition threshold (SRT), most comfortable loudness level (MCL), uncomfortable loudness level (UCL), and discrimination with proper masking when needed;
   5. e. Interpreting hearing tests and the making of medical referrals as necessary;
   6. f. Taking of ear impressions suitable for hearing aids and ear molds;
   7. g. Fitting and post-fitting adjustments;
   8. h. Checking for proper fit and making needed adjustments;
   9. i. Verifying the hearing aid performance to determine if the hearing aid is correcting and conforming to the hearing loss as expected. This may include, but is not limited to, the user of real ear measurement, word discrimination, aided versus unaided, or other forms of aided measurements as may be standard in the industry; and j. Counseling, including the delivery of the hearing aid, insertion and removal of the hearing aid, instruction on changing the batteries, and education to the user and family as to the expectations and performance.
4. 4. Once an apprentice has successfully completed his/her 300 documented hours of initial supervised training, then he/she may perform any of the activities in paragraph (3) above under the direct supervision of an audiologist. However, all hearing aid sales must be reviewed by the supervising audiologist and all contracts need to be signed by the supervising audiologist.
5. 5. An apprentice is eligible to become a licensed hearing aid provider upon successful completion of at least six months of training under direct supervision, including a minimum of 300 documented hours of on-site supervised training, and passage of the International Licensing Examination (ILE), developed by the International Hearing Society (IHS), or another appropriate entry-level examination approved by the Director.

1.8 Reporting Convictions and Other Adverse Actions

The purpose of this Rule is to clarify the procedures for reporting convictions and other adverse actions to include judgments and administrative proceedings pursuant to sections 12-210-105(5), 12-210-108(2)(c) and (u), 12-210-108(4), and 12-30-102, C.R.S. A Licensee, as defined in section 12-20-102(10), C.R.S., shall inform the Office of Audiology Licensure, in a manner set forth by the Director, within thirty days of any adverse action. For purposes of this Rule, “adverse action” includes the following:

A. Conviction or acceptance of a plea of guilty or nolo contendere or receipt of a deferred sentence in any court to a felony, or a crime involving fraud, deception, false pretense, theft, misrepresentation, false advertising, or dishonest dealing.

B. A disciplinary action imposed upon the licensee by another jurisdiction which would or could reasonably be considered to be a violation of Article 210, Title 12, C.R.S. For purposes of this Rule any disciplinary action by another jurisdiction includes, but is not limited to, a revocation, suspension, probation, fine, sanction, or a denial of a license or authorization to practice.

C. Any judgment, award, or settlement of a civil action or arbitration in which there was a final judgment or settlement against the licensee for failing to practice according to generally accepted professional standards.

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

1. 1. If the event is an action by a governmental agency (as described above): the name of the agency, its jurisdiction, the case name, the docket, proceeding or case number by which the event is designated, and a copy of the consent decree, order, or decision;
2. 2. If the event is a felony conviction or a conviction of a crime involving fraud, deception, false pretense, theft, misrepresentation, false advertising, or dishonest dealing: 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 or 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 within 90 days of such action; and 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.

E. The licensee may submit a written statement with any notice under this Rule to be included in the licensee records.

F. This rule shall apply to any adverse action as described in section (A) of this Rule that occurs on or after the effective date of this rule.

1.9 Duty to Report Information

The purpose of this Rule is to clarify the requirement of licensees to notify the Director of a change in submitted information pursuant to sections 12-30-102 and 12-210-108(2)(b), C.R.S.

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

1. 1. The Division of Professions and Occupations 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 Audiology 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.

1.10 Declaratory Orders

The purpose of this Rule is to clarify 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 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 or his discretion and without notice to petitioner, whether to rule upon any such petition. If the Director determines that she or he will not rule upon such a petition, the Director shall promptly notify the petitioner of her or his 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 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 licensed pursuant to Title 12, Article 210.
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 or he 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 or his 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 or he shall promptly notify the petitioner of her decision.
3. 3. The Director may, at her or his 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. For the purpose of such a hearing, to the extent necessary, the petitioner shall have the burden of proving all 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 an agency action subject to judicial review pursuant to the Colorado Administrative Procedures Act at section 24-4-106, C.R.S.

1.11 Credit for Military Education, Training, or Experience and Pathways to Licensure for Veterans and Members of the Military The purpose of this Rule is to provide pathways to licensure for individuals with training, education, or experience gained during military service pursuant to sections 12-20-202(4) and 24-4-201 et seq., C.R.S.

A. An applicant for licensure 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 licensure.

D. Documentation of military experience, education, or training may include, but is not limited to, the applicant’s Certificate of Release or Discharge from Active Duty (DD-214), Verification of Military Experience and Training (DD-2586), military transcript, training records, evaluation reports, or letters from commanding officers describing the applicant’s practice.

1.12 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 12-210-109(4), 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. 1. “Ancillary Services” as defined in section 12-30-112(1)(a), C.R.S.
2. 2. “Balance Bill” and “Balance Billing” as defined in section 10-16-704(19)(c), C.R.S.
3. 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. 4. “Covered Person” as defined by section 10-16-102(15), C.R.S.
5. 5. “Health Benefit Plan” as defined by section 10-16-102(32), C.R.S.
6. 6. “Health Care Provider” means “provider,” as defined in section 10-16-102(56), C.R.S.
7. 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. 8. “Out-of-Network Provider” means a Health Care Provider who is not a “Participating Provider.”
9. 9. “Participating Provider” as defined in section 10-16-102(46), C.R.S.
10. 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. 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. 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 A 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. 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 12-210-108(2)(d), C.R.S.

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

SEXUAL MISCONDUCT 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 registrant 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 acknowledgement;
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. 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. APPENDIX A BALANCE BILLING NOTICE PATIENT RIGHTS INFORMATION Check the appropriate box:

1. 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. 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. 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)

1. 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] 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 section 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;
3. 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 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:

_________________________________________________________________________ Editor’s Notes History Entire rule eff. 09/01/2010.

Entire rule emer. rule eff. 07/01/2013.

Entire rule eff. 10/15/2013.

Entire rule eff. 12/30/2013.

Rules 2, 11 eff. 07/30/2019.

Rule 1.12, Appendix A emer. rules eff. 01/01/2020; expired 04/29/2020. Rule 1.12, Appendix A eff. 04/30/2020.

Rule 1.6 emer. rule eff. 10/21/2020.

Rules 1.2, 1.6, 1.13, Appendix B eff. 12/15/2020.

Rules 1.2 A.1, 1.13 D-F eff. 05/30/2021.

Rule 1.9 B eff. 11/14/2021.

Rule 1.3 eff. 06/30/2022.

Rules 1.14, 1.15 emer. rules eff. 08/15/2022.

Rule 1.2 A eff. 09/14/2022.

Rules 1.12, 1.14, 1.15, Appendix A eff. 11/30/2022.

Rules 1.14, 1.15 repealed eff. 12/30/2023.

Rule 1.12, Appendix A eff. 11/14/2025.

Annotations Rules 1.2 A.1, 1.13 C.4 (adopted 10/21/2020) were not extended by Senate Bill 21-152 and therefore expired 05/15/2021.

Rules 1.15 B. and 1.15 C. (adopted 10/10/2022) were not extended by Senate Bill 23-102 and therefore expired 05/15/2023.