4 CCR 749-1-A - Naturopathic Doctor Disclosure Statement and Consent for Treatment
Naturopathic Doctor Name:
____________________________________________________________________________________
Business Address & Phone Number: ______________________________________________________
____________________________________________________________________________________
The nature of the services the Naturopathic Doctor will be providing:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Naturopathic Doctors may be registered in other states. This Naturopathic Doctor is registered or licensed in the following state(s):
_______________________________________________________
Complaints regarding this Naturopathic Doctor must be submitted in writing to the Office of Naturopathic Doctor Registration. To obtain a complaint form, contact the Division at (303) 894-7414 or find more information on how to file a complaint at: www.colorado.gov/pacific/dora/DPO_File_Complaint
Naturopathic Doctors are registered by the state to practice naturopathic medicine under the "Naturopathic Doctor Act." They are not permitted to perform the following acts:
* Prescribe, dispense, or administer any prescription medications or devices except:
* Epinephrine for anaphylaxis,
* Vitamins B6 and B12
* Barrier contraceptives (not including intrauterine devices),
* Oxygen for emergency use, and
* Vaccines in accordance with ACIP guidelines for patients who are at least eighteen years of age.
* Perform surgical procedures, including surgical procedures using a laser device.
* Use general or spinal anesthetics, other than topical and local anesthetics, including anesthetics with epinephrine.
* Administer ionizing radioactive substances for therapeutic purposes.
* Treat a child who is less than two years old, unless:
(1) This form is fully completed and signed;
(2) The most recent immunization schedule recommended by the Advisory Committee on Immunization Practices to the Centers for Disease Control and Prevention in the federal Department of Health and Human Services is provided to the parent or legal guardian with this form,
(3) The Naturopathic Doctor develops and executes a written collaborative agreement with a licensed physician who is a pediatrician or family physician; and
(4) The Naturopathic Doctor provides a release of information to the parent or guardian requesting permission to exchange information and enter into a collaborative relationship with the child's licensed pediatric health care provider, if the child has one.
* Treat a child who is two years of age or older, but less than eight years of age, unless:
(1) This form is fully completed and signed;
(2) The most recent immunizations schedule recommended by the Advisory Committee on Immunization Practices to the Centers for Disease Control and Prevention in the federal Department of Health and Human Services is provided to the parent or guardian with this form; and
(3) The Naturopathic Doctor provides a release of information to the parent or guardian requesting permission to exchange information and enter into a collaborative relationship with the child's licensed pediatric health care provider, if the child has one.
* Practice medicine, surgery, or any other form of healing other than Naturopathic Medicine.
* Practice obstetrics.
* Perform chiropractic services (spinal adjustments, manipulation, or mobilization). Naturopathic physical medicine, as described in section 12-250-103(13)(b), C.R.S., is permitted.
* Recommend the discontinuation of, or counsel against, a course of care, including a prescription drug that was recommended by another health care practitioner licensed in Colorado, unless the Naturopathic Doctor consults with the health care practitioner.
Disclosure Statement (To be completed by the Naturopathic Doctor)
1. I, ____________________________________ (print Naturopathic Doctor name), am a
Naturopathic Doctor registered under Title 12, Article 250, of the Colorado Revised Statutes.
2. I am not a medical doctor or a physician licensed under Title 12, Article 240, of the Colorado Revised Statutes.
3. I recommend that the patient named below have a relationship with a licensed physician, or if the patient is a child aged less than eight, with a licensed pediatric health care provider. If the patient is less than two and does not have a relationship with a licensed pediatric health care provider, I
refer the patient to _____________________________ (print name of licensed pediatric health care provider, physician, or advanced practice nurse who cares for pediatric patients).
4. If the patient is a child aged less than eight, I have provided the immunization schedule that accompanies this form and I recommend that that the child's parent or guardian follow the immunizations schedule that accompanies this form.
5. If the patient has a relationship with a licensed physician or pediatric health care provider, I will attempt to develop and maintain a collaborative relationship with the physician or pediatric health care provider. To permit this, the patient (or patient's parent/guardian if patient is a minor) will need to sign a separate release allowing me to exchange information with the licensed physician or pediatric health care provider.
__________________________________________________ _______________________________
Naturopathic Doctor Signature Date
Acknowledgement and Consent for Treatment (to be completed by the adult patient, or parent/guardian if patient is a minor)
I, __________________________________________ (print adult patient's name, or if the patient is a minor, the parent or guardian name), acknowledge receipt of the above disclosure statement and give my informed consent for treatment for (circle one) myself or my child,
_________________________________________________ (print patient's name) by the above named
Naturopathic Doctor.
Check one:
The patient _____ does _____ does not have a relationship with a licensed physician or pediatric health care provider.
Name, address, phone of licensed physician or pediatric health care provider:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________ _________________________________
Signature of Patient/Parent or Guardian Date
(This form must be completed and signed prior to the initial examination of the patient. If this form is altered, the form provided to the patient must contain all of the information detailed in this form, and comply with ยงยง 12-250-106(2)(e) and (f), (3)(b), and 12-250-112, C.R.S., and all other laws applicable to Naturopathic Doctors.)
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.