4 CCR 738-1
DEPARTMENT OF REGULATORY AGENCIES ACUPUNCTURE LICENSURE RULES AND REGULATIONS 4 CCR 738-1 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________
1.1 Requirement for Licensure
The purpose of this Rule is to establish the qualifications for an acupuncturist license as required in sections 12-200-106(3) and 12-20-202(4), C.R.S.
A. In order to qualify for licensure - an applicant must demonstrate the following:
1. Graduation from a diploma program in acupuncture and Oriental medicine accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) or successor organization and successful completion of the NCCAOM Board examinations; the California Licensure Examination or a substantially equivalent examination as determined by the Director; or 2. Graduation from a non-accredited diploma program in acupuncture and Oriental medicine that is substantially equivalent to a program accredited by the ACAOM as determined by the Director and a certification issued by NCCAOM or a successor organization.
B. 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 Director, 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.
1.2 Licensure by Endorsement
The purpose of this Rule is to establish the experience or credentials deemed substantially equivalent for an acupuncturist license by endorsement pursuant to section 12-20-202(3), C.R.S.
A. For an applicant to establish “substantially equivalent experience or credentials” under section 12-20-202(3), C.R.S., the applicant must demonstrate:
1. Graduation from a diploma program in acupuncture and Oriental medicine accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) or a successor organization; and successful completion of the NCCAOM examination, the California Licensing Examination; or a substantially equivalent examination as determined by the Director;
2. Graduation from a non-accredited diploma program in acupuncture and Oriental medicine that is substantially equivalent to a program accredited by the ACAOM as determined by the Director and a certification by NCCAOM or a successor organization; or 3. Having held for at least one year a current and valid acupuncturist license in a jurisdiction with a scope of practice that is substantially similar to the scope of practice for acupuncturists as defined under Article 200, of Title 12, C.R.S.
B. Verification of licensure in another state, through the federal government, or in a military occupational specialty, as defined in section 24-4-201, C.R.S., shall be provided in a manner prescribed by the Director.
1.3 Requirements for Reinstatement
The purpose of this Rule is to state the requirements for reinstatement of a license that has expired, pursuant to section 12-200-106(4), C.R.S.
A. An applicant seeking reinstatement of an expired license shall complete a reinstatement application, pay a reinstatement fee, and attest to malpractice insurance in the amount required by statute.
B. If the license has been expired for more than two years from the date of receipt of the reinstatement application, but less than five years an applicant shall establish competency to practice under sections 12-20-202(2)(c)(II), C.R.S., and 12-20-105, C.R.S., by demonstrating one of the following:
1. Licensure in good standing from another state along with proof of active practice in that state for two years of the previous five years from the date of application for reinstatement.
2. Completion of thirty hours of continuing education courses related to the practice of acupuncture during the two years immediately preceding the application for reinstatement. The continuing education must meet the approval of and shall be attested to in a manner prescribed by the Director.
3. Active certification by NCCAOM or a successor organization.
4. Competency to practice by any other means approved by the Director.
C. An applicant seeking to reinstate a license that has been expired for more than five years shall establish competency to practice as required in section 12-20-202(2)(c)(II), C.R.S. by demonstrating one of the following:
1. Licensure in good standing from another state along with proof of active practice for two years of the previous five years from the date of application for reinstatement.
2. Completion of supervised practice for a period no less than six months subject to the terms established by the Director.
3. Competency to practice by any other means approved by the Director.
1.4 Unlicensed Persons in Acupuncture Training Programs
The purpose of this Rule is to identify the circumstances and conditions under which a person in training may practice acupuncture without a valid and current license on file with the Division of Professions and Occupations pursuant to section 12-200-108(3), C.R.S.
A. A person in training may practice acupuncture without a valid and current license issued by the Division of Professions and Occupations if such practice takes place in the course of a bona fide training program. A bona fide training program is a training or apprenticeship program with an accredited school of acupuncture.
B. A person in training shall be supervised by an acupuncturist licensed in Colorado who holds an active and unrestricted license to practice acupuncture in Colorado.
C. Section 12-200-108(3), C.R.S., requires a supervising acupuncturist to provide direct, on-site supervision of persons in training. Direct supervision shall mean supervision that is on the premises and in the same building where any such persons in training are practicing.
D. A person in training may engage in the full scope of the practice of acupuncture as defined in section 12-200-103(5)(a), C.R.S.
E. The supervising acupuncturist is responsible for maintaining documentation detailing the beginning and ending dates of the bona fide training program and for ensuring that the names and current addresses of all supervised persons in training are maintained by the supervising acupuncturist and are readily available for inspection at the request of the Director or designee.
1.5 Use of Title and Restrictions
The purpose of this Rule is to clarify the use of title “licensed acupuncturist” and “diplomat of acupuncture”, and use of the designations “L.Ac.” and “Dipl. Ac.” under section 12-200-108(2)(b)(II), C.R.S.
A. Obtaining an acupuncturist license does not automatically entitle or confer upon the licensee the right to use the title “Dr.” or “Doctor.”
B. A licensed acupuncturist can use the title “Doctor” or Dr. only when such licensee has, in fact, been awarded a doctorate degree from an acupuncture or oriental medicine academic/educational institution and satisfies the requirements of section 6-1-707, C.R.S.
C. In such instances where a licensee qualifies to use the title “Doctor” or “Dr.”, an acupuncturist can use the title “Doctor” or “Dr.” only when accompanied by the words “Doctor of Acupuncture” or letters “D.Ac.”, “Oriental Medicine Doctor” or “OMD”, “Doctor of Acupuncture and Oriental Medicine” or “D.Ac.OM”, “Doctor of Traditional Chinese Medicine” or “DTCM”, “Doctor of Acupuncture and Oriental Medicine” or “DAOM”, or any other doctoral degree recognized and approved by the Director.
1.6 Declaratory Orders
The purpose of this Rule is to establish procedures for the handling of requests for declaratory orders filed pursuant to the Colorado Administrative Procedures Act at section 24-4-105(11), C.R.S.
A. Any person or entity may petition the Director for a declaratory order to terminate controversies or remove uncertainties as to the applicability of any statutory provision or of any rule or order of the Director.
B. The Director will determine, at her discretion and without notice to petitioner, whether to rule upon such petition. If the Director determines that the Director will not rule upon such a petition, the Director shall promptly notify the petitioner of the 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. 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. 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. 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. 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 Colorado Rules of Civil Procedure 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. The name and address of the petitioner and whether the petitioner is licensed pursuant to Title 12, Article 200.
2. The statute, rule, or order to which the petition relates.
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 decides to rule on the petition, the following procedures shall apply:
1. The Director may rule upon the petition based solely upon the facts presented in the petition. In such a case:
2. If the Director rules upon the petition without a hearing, the Director shall promptly notify the petitioner of her decision.
3. The Director may, at the Director’s 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 hearing notice to the petitioner shall set forth, to the extent known, the factual or other matters that the Director intends to inquire.
F. The parties to any proceeding pursuant to this rule shall be the Director and the petitioner. Any other person may seek leave of the Director to intervene in such a proceeding, and leave to intervene will be granted at the sole discretion of the Director. A petition to intervene shall set forth the same matters as are required by Section D of this Rule. Any reference to a “petitioner” in this rule also refers to any person who has been granted leave to intervene by the Director.
G. Any declaratory order or other order disposing of a petition pursuant to this rule shall constitute agency action subject to judicial review pursuant to the Colorado Administrative Procedures Act at section 24-4-106, C.R.S.
1.7 Reporting Convictions, Judgments and Administrative Proceedings
The purpose of the Rule is to clarify the procedures for reporting convictions, and other adverse actions to include judgments and administrative proceedings pursuant to sections 12-200-105, 12-200-106, and 12- 200-109, C.R.S.
A licensee as defined in section 12-200-103, C.R.S., shall inform the Director, in a manner set forth by the Director, within thirty days of any of the following events:
A. The conviction of the licensee of a felony under the laws of any state or of the United States, which would be a violation of section 12-200-109(1)(n), C.R.S. A guilty verdict, a plea of guilty or a plea of nolo contendere (no contest) accepted by the court is considered a conviction;
B. A disciplinary action imposed upon the licensee by another jurisdiction that licenses acupuncturists, which would be a violation of section 12-200-109, C.R.S., including, but not limited to, a citation, sanction, probation, civil penalty, or a denial, suspension, revocation, or modification of a license whether it is imposed by consent decree, order, or other decision, for any cause other than failure to pay a license fee by the due date or failure to meet continuing professional education requirements;
C. Revocation or suspension by another state board, municipality, federal or state agency of any health services related license, other than a lapsed license for acupuncture as described in Section 12-200-109, C.R.S.;
D. Any judgment, award or settlement of a civil action or arbitration in which there was a final judgment or settlement against the licensee for malpractice of acupuncture.
E. The notice to the Director shall include the following information;
1. If the event is an action by a governmental agency (as described above), the name of the agency, its jurisdiction, the case name, court docket, proceeding or case number by which the event is designated, and a copy of the consent decree, order or decision;
2. If the event is a felony conviction, the court, its jurisdiction, the case name, the case number, a description of the matter or a copy of the indictment or charges, and any plea or verdict entered by the court. The licensee shall also provide to the Director a copy of the imposition of sentence or judgment, whether deferred or immediate, related to the felony conviction and the completion of all terms of the sentence or judgment with thirty
3. If the event concerns a civil action or arbitration proceeding, the court or arbiter, the jurisdiction, the case name, the case number, court docket, a description of the matter or a copy of the complaint, and a copy of the verdict, the court or arbitration decision, or, if settled, the settlement agreement and court’s order of dismissal;
F. The licensee notifying the Director may submit a written statement with the notice to be included with the licensee records.
1.8 Exceptions and Director’s Review of Initial Decisions (Repealed)
1.9 Duty to Self-Report Certain Medical Conditions (Section 12-200-112, C.R.S.)
A. No later than thirty days from the date a physical or mental illness or condition that affects a licensee’s ability to perform acupuncture services with reasonable skill and safety, the licensee shall provide the Director, 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; and 4. A description of the acupuncturist’s practice and any modifications, limitations or restrictions to that practice that have been made as a result of the illness or condition.
B. The licensee shall notify the Director of any worsening of any worsening of the illness or condition, or any significant change in the illness or condition that affects the licensee’s ability to practice with reasonable skill and safety, within thirty days of the change of the illness or condition. The acupuncturist shall provide to the Director, in writing, the following information:
1. The name of the current treatment provider, documentation from the current treatment provider confirming the change of the illness or condition, the date that the illness or condition changed, the nature of the change of the illness or condition, and the current treatment plan; and 2. A description of the licensee’s practice, and any modifications, limitations, or restrictions to that practice that have been made as a result of the change of condition.
C. Compliance with this Rule is a prerequisite for eligibility to enter into a Confidential Agreement with the Director pursuant to section 12-200-112(1), C.R.S. However, mere compliance with this rule does not require the Director to enter into a Confidential Agreement. Rather, the Director will evaluate all facts and circumstances to determine whether a Confidential Agreement is appropriate.
D. If the Director discovers that a licensee has a mental or physical illness or condition that affects the licensee’s ability to practice with reasonable skill and safety, and the licensee has not timely notified the Director of such illness or condition, the licensee may be subject to disciplinary action pursuant to section 12-200-109(1)(l), C.R.S.
1.10 Injection Therapy
A. Definitions. For purposes of this Rule only:
1. The Director recognizes that “Injection therapy” is the stimulation of acupuncture points, including trigger points(historically known as “AHSHI” points), by the injection of saline, sterile herbs, vitamins, minerals, homeopathic substances, glucose, lidocaine, procaine, and sarapin, or other similar substances specifically manufactured for nonintravenous injection by means of hypodermic needles.
B. Except as restricted by paragraph (C) of this Rule, an acupuncturist with an active license may practice injection therapy in the treatment of patients in his or her care, C. Requirements to Practice Injection Therapy. The acupuncturist shall:
1. Possess a Colorado acupuncture license in good standing;
2. Hold a current Clean Needle Technique Certificate through the NCCAOM (or successor organization); and 3. Be current in basic life support (BLS) or cardiopulmonary resuscitation (CPR) approved by the American Heart Association or American Red Cross;
4. Complete educational coursework covered in subsection D.
D. Acupuncturists employing injection therapy shall use only those substances and techniques for which they have received training. Required Educational Coursework shall include:
1. Anatomy and Physiology;
2. Acupuncture physical exam and differential diagnosis;
3. Acupuncture point location, including underlying anatomy;
4. Acupuncture needling technique;
5. General injection safety;
6. Acupuncture point injection therapy;
7. Pharmacology; and 8. Clean Needle Technique.
9. For the use of injectable substances prepared from sterile herbs, completion of training in Chinese herbology and injection of Chinese herbal injectables is required. To demonstrate satisfying the training requirements in Chinese herbology and injection of Chinese herbal injectables the Director will accept NCCAOM, or a successor organization’s, certification in Chinese herbology and/or certification in Oriental Medicine.
10. For the use of substances listed in (E)(3)(a)(12-17), instruction on the use of inhaled O2 and IM epinephrine for emergency use is required.
E. Permissible Substances 1. An acupuncturist shall comply with all federal and state laws that pertain to obtaining, possessing and administering any drug;
2. A substance shall only be approved for use if procured in compliance with all federal and state laws;
3. The following drugs are authorized in the modes of administration that are specified except as limited or restricted by federal or state law:
F. Patient safety.
1. Acupuncturists shall have an adverse event/emergency plan in place.
2. An acupuncturist practicing injection therapy of substances listed in (E)(3)(a)(12)-(17) shall be equipped and trained to treat patients with oxygen and epinephrine. The oxygen and emergency epinephrine kit shall be on site where injection therapy utilizing substances with potential allergic side effects are being rendered.
3. An acupuncturist authorized to practice injection therapy shall not inject any substance intravenously.
G. Acupuncturists shall show current medical malpractice coverage for this procedure and maintain coverage.
1. It is the acupuncturist’s responsibility to only inject substances that are listed in subsection E and are explicitly covered by the acupuncturist’s insurance policy obtained in compliance with section 12-200-106(6), C.R.S.
1.11 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 12-200-114(1)(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 A to 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 12-200-109(1)(i) and 12-200-110, C.R.S.
1.12 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. 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. 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 is not required to provide the written disclosure before providing professional services to the patient in the following instances 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 acknowledgment;
2. The visit occurs in an emergency room or freestanding emergency department or the visit is unscheduled, including consultations in inpatient facilities; or 3. The provider who will be treating the patient during the visit is not known to the patient until immediately prior to the start of the visit.
F. The provider who does not have a direct treatment relationship or have direct contact with the patient is not required to make the disclosure required by this section.
1.13 Regarding the Delegation and Supervision of Acupuncture Services to Unlicensed Persons pursuant to section 12-200-114(1)(k), C.R.S.
This Rule is promulgated pursuant to sections 12-20-204, 12-200-114(1)(a) and (k), C.R.S. This Rule applies to the delegation of services constituting the practice of acupuncture to a person who is not licensed to practice acupuncture is not qualified for licensure as an acupuncturist, and is not otherwise exempt pursuant to section 12-200-108(1) and (2), C.R.S.
A. Acupuncture Services that may be Delegated. Delegated acupuncture services should be limited to routine, technical services that do not require the special skills of a licensed acupuncturist. Services that may be delegated include but are not limited to:
1. Taking and monitoring vital signs;
2. Needle removal;
3. Moxa monitoring; and 4. Acupressure.
B. Acupuncture Services that may not be Delegated. A licensed acupuncturist should not delegate an acupuncture service requiring the exercise of clinical judgement by the delegatee. Services that may not be delegated include but are not limited to:
1. Diagnosis;
2. Point location;
3. Needle insertion; and 4. Electrical stimulation.
C. Persons Who May Serve as Delagatee. The delegating acupuncturist must evaluate and determine that the delegate has the necessary education, training, or experience to perform each delegated acupuncture service. As part of his or her evaluation, the delegating acupuncturist shall:
1. Personally assess and review copies of diplomas, certificates, or professional degrees from bona fide training program(s) appropriate to the specific services delegated;
2. Perform over-the-shoulder, direct observation of the delegatee’s performance of any acupuncture service prior to authorizing the delegate to perform the acupuncture service outside of the delegating acupuncturist’s physical presence; and 3. Provide ongoing inspection, evaluation, advice, and control; and 4. Monitor the quality of the services provided by the delagatee.
D. Persons Who May Not Serve as Delagatee. An acupuncturist shall not delegate services to any person who is otherwise qualified to be licensed as an acupuncturist but who is not licensed, including, but not limited to:
1. Any person with an inactive, expired, revoked, restricted, limited, suspended, or surrendered license to practice acupuncture;
2. Any person who meets all qualifications for acupuncture licensure but who is not licensed in Colorado; or 3. Any person whose application for licensure in Colorado has been denied.
E. Exceptions.
1. This Rule does not apply to persons performing acts that do not constitute the practice of acupuncture as defined by section 12-200-103(1), C.R.S.
2. This Rule does not apply to persons who are licensed, registered, or certified by Colorado and who are acting within their scope of practice.
3. This Rule does not apply to any person who is otherwise exempt pursuant to section 12- 200-108(3), C.R.S.
F. Supervision. A delegating acupuncturist must be on the premises and readily available APPENDIX A 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] 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 section 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 section 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. 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 provider’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 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. 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 provider, including information on how to file a complaint. Sample Signature Block I have received and read the sexual misconduct disclosure by [Provider Name] and I agree to treatment by [Provider Name].
_______________________________________________________________ Print Client Name _______________________________________________________________ Client or Responsible Party’s Signature Date If signed by Responsible Party (parent, legal guardian, or custodian), print Responsible Party’s name and relationship to client:
_______________________________________________________________ Print Responsible Party Name Print Relationship to Client _______________________________________________________________ Provider Signature Date ________________________________________________________________________ Editor’s Notes 4 CCR 738-2 through 4 CCR 738-6 were recodified as 4 CCR 738-1 Rules 2 through 6 eff. 10/01/2009. History Entire rule eff. 10/01/2009.
Entire rule eff. 01/01/2011.
Rule 1 eff. 11/14/2012.
Entire rule eff. 05/30/2016.
Rule 1.11, Appendix A emer. rules eff. 01/01/2020; expired 04/29/2020. Rule 1.11, Appendix A eff. 04/30/2020.
Rules 1.1, 1.2, 1.12, Appendix B eff. 12/15/2020.
Rules 1.12 E-F eff. 05/30/2021.
Rules 1.10 D.9, 1.10 E.3.a.(15), 1.13-1.15, Appendix A repealed emer. rules eff. 08/15/2022. Rules 1.2, 1.10 D.9, 1.10 E.3.a.(15), 1.11, 1.13-1.15, Appendix A eff. 11/30/2022. Rules 1.14, 1.15 repealed eff. 12/30/2023.
Rule 1.11, Appendix A eff. 09/14/2025.
Annotations Rule 1.12 E.4 (adopted 10/21/2020) was not extended by Senate Bill 21-152 and therefore expired 05/15/2021.
Rules 1.15 B. and 1.15 C. (adopted 10/07/2022) were not extended by Senate Bill 23-102 and therefore expired 05/15/2023.