3 CCR 713-30-A - Agreement Between Delegating Physician and Delegatee Performing Medical Services Under Colorado Medical Board Rule 800

_______________________________________________________________________________ and

(Print Name & Title of Delegating Physician)

_______________________________________________________________________________ ,

attest that: (Print Name & Title of Delegatee)

The delegating physician is licensed in the state of Colorado to practice medicine.

The delegating physician is qualified to perform each delegated medical service listed below, and actively performs each listed medical service as part of his or her medical practice and not exclusively by delegating the medical service to a delegatee.

The delegated services listed below are routine, technical services, the performance of which does not require the special skills of a licensed physician.

The delegating physician is insured to delegate the delegated services listed below.

The delegating physician is not legally restricted from performing the delegated services listed below.

The delegating physician is providing personal and responsible direction and supervision to the delegatee by complying with Colorado Medical Board Rule 800 ("Rule 800").

The delegating physician is delegating the following services and understands that (s)he is fully accountable for the performance of these services by the delegatee. (Note: the description of the delegated medical services must be specific and detailed.)

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The delegated medical services will be performed at the following facilities. (Note:please include the name and address of each facility.]

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The delegating physician has personally assessed the qualifications and competence of the delegatee to perform the Medical Services listed above. The assessment included, but was not limited to, initial over-the-shoulder monitoring of the delegatee's performance of each delegated Medical Service. The delegating physician will reassess the competence and performance of the delegatee on at least an annual basis as set forth in Rule 800.

It is agreed that all patients receiving a delegated Medical Service will be informed that the delegating physician is available personally to consult with them or provide appropriate evaluation or treatment in relation to the delegated Medical Services. The delegating physician shall timely and personally provide such consultation, evaluation or treatment to the patient upon request. The delegating physician will ensure that each patient receives all information to give appropriate informed consent for any Medical Services and that such informed consent is timely documented in the patient's chart.

In the event of an adverse outcome resulting from a delegated medical service, the delegating physician will provide appropriate follow-up care and/or referrals.

It is expressly agreed that the delegatee will only provide the delegated services listed in this document, unless the delegatee is separately licensed or otherwise legally authorized to provide other services not listed in this document.

This agreement shall remain in effect until formally rescinded in writing by either party.

______________________________________ ___________________________________

(Signature & Title of Delegating Physician) (Signature of Delegatee)

_______________________________________ ___________________________________

(Date) (Date)

Notes

3 CCR 713-30-A

40 CR 10, May 25, 2017, effective 6/14/2017