4 CCR 749-1-B - SAMPLE COLLABORATIVE AGREEMENT FOR THE TREATMENT OF CHILDREN UNDER TWO

The following parties agree to a collaborative arrangement in which the naturopathic doctor (ND) may consult with the Colorado licensed physician (pediatrician or family MD/DO) regarding patients under 2 years and refer to a physician. The purpose of this agreement is to facilitate the effective treatment of the patient.

Specific responsibilities of naturopathic doctor: ___________________________________________________________________________________

___________________________________________________________________________________

Specific responsibilities of licensed physician:

___________________________________________________________________________________

___________________________________________________________________________________

Process for consulting with licensed physician, including the means, e.g., in person, via phone, or via telehealth, and the frequency, e.g., per visit, on an as needed basis, or regularly scheduled on a weekly, monthly or quarterly basis):

___________________________________________________________________________________

___________________________________________________________________________________

Process for referring the patient to a licensed physician to facilitate the effective treatment of the child:

___________________________________________________________________________________

___________________________________________________________________________________

Emergency plan:

___________________________________________________________________________________

___________________________________________________________________________________

* This agreement does not limit the ability of the ND to make an independent judgment.

* This agreement does not require medical supervision of the ND by the physician.

* Neither party assumes liability for the actions of the other.

* The above parties do not have to be practicing in close proximity to one another.

* This agreement will be kept on file in both parties' respective patient file.

Naturopathic Doctor:

Name: ______________________________________________________________________________

Practice name ________________________________________________________________________

Address: ____________________________________________________________________________

Phone number: _________________________________ Cell number: __________________________

Fax: ________________________________________________________________________________

Email: ______________________________________________________________________________

Registration #: ________________________________________________________________________

Signature: ___________________________________________________________________________

Colorado Physician:

Name:______________________________________________________________________________

Practice name: _______________________________________________________________________

Add ress:_____________________________________________________________________________

Phone number: _________________________________Cell number:___________________________

Fax:________________________________________________________________________________

Email:_______________________________________________________________________________

License #:___________________________________________________________________________

Signature:___________________________________________________________________________

Notes

4 CCR 749-1-B

37 CR 15, August 10, 2014, effective 8/30/2014 38 CR 11, June 10, 2015, effective 7/1/2015 39 CR 11, June 10, 2016, effective 6/30/2016 43 CR 03, February 10, 2020, effective 1/1/2020 43 CR 07, April 10, 2020, effective 4/30/2020 43 CR 22, November 25, 2020, effective 12/15/2020 44 CR 09, May 10, 2021, effective 5/30/2021 45 CR 17, September 10, 2022, effective 8/15/2022 45 CR 16, August 25, 2022, effective 9/14/2022 45 CR 21, November 10, 2022, effective 11/30/2022