COLORADO MEDICAL BOARD
POLICIES
Table of Contents
Discipline & Enforcement
10-1
Protocol 30-Day Letters .................................................................................................... 1
10-2
Release of Investigatory File Information (Re-located to 30-5)
10-3
Retention of Letters of Concern .......................................................................................... 2
10-4
Release of Active Complaint Information for Law Enforcement or Criminal Justice Purposes (Re-located
to 30-6)
10-5
Disciplinary Actions Taken Against Colorado Licensees Holding Expired or Inactive Licenses by Other
State Boards or Governmental Agencies ................................................................................. 3
10-6
Orders to CPHP .............................................................................................................. 4
10-7
Combined with Policy 10-06, effective 2/19/15
10-8
Anonymous Complaints ..................................................................................................... 5
10-9
Enforcement of Injunctive Actions .......................................................................................6
10-10
Investigative Subpoena Enforcement..................................................................................... 7
10-11
Delegation of Authority to Division and Program Directors (Re-located to 30-10)
10-12
Sexual Misconduct Statement and Policy (Re-located to 40-25)
10-13
Policy Repealed 11/8/01
10-14
Policy repealed 8/15/13
10-15
Eligibility to Serve as a Practice Monitor ................................................................................ 8
10-16
Subpoena of Plaintiff's Records in Malpractice Cases ................................................................. 9
10-17
Process for Handling Complaints Involving Board Members or Licensees with Ongoing Formal Relationships
with the Board ............................................................................................................. 10
10-18
Public Disciplinary Documents (Relocated to 30-9)
10-19
Scope of Investigations .................................................................................................. 11
10-20
Supplemental Informal Complaints ..................................................................................... 12
10-21
Practice Monitoring Compliance Policy ................................................................................ 13
10-22
Release of Active Complaint and Investigatory Information to Physician Training Programs (Re-located
to 30-7)
10-23
Process for Handling Initial Decisions .................................................................................. 14
10-24
Special Appearances before the Inquiry Panel ....................................................................... 15
10-25
Issuance of Letters of Concern for certain Criminal Convictions ................................................. 16
10-26
Policy for Prescribing and Dispensing Opioids (Re-located to 40-26)
10-27
Reporting Physical and Mental Illnesses or Conditions to the Board ............................................. 17
Licensing
20-1
Release of Information from Application Files (Re-located to 30-8)
20-2
Reporting of Applicants to the Federation of State Medical Boards.............................................. 19
20-3
Repealed 5/16/02
20-4
Issuance of Administrative or Restricted Licenses................................................................... 20
20-5
Review of International Medical Schools .............................................................................. 21
20-6
Continued Competency and the Practice of Administrative Medicine ........................................... 23
20-7
Repealed 8/19/10
20-8
Repealed 8/19/10
20-9
Physician Assistants Registration of Primary Physician Supervisor ............................................... 24
20-10
Repealed 8/19/10
20-11
Reinstatement of Lapsed Licenses ..................................................................................... 25
20-12
Reactivation of Inactive Licenses ....................................................................................... 26
20-13
Ability of Unlicensed Physician Assistants to Provide Delegated Medical Services Pursuant to 12-36106(3)(l), C.R.S. ........................................................................................................... 27
20-14
Administrative Approval of Applications .............................................................................. 28
20-15
Purging Incomplete Applications ........................................................................................ 29
20-16
Criteria to Identify Applications Requiring Board Review .......................................................... 30
20-17
Referral of Applicants to the Colorado Physician Health Program for Evaluation ............................. 32
20-18
Physician Training Programs ............................................................................................. 33
20-19
Clarification of the 60-day Rotation Exemption from Licensure/Physician Training Licensure
Requirements Pursuant to § 12-36-106(3)(v), C.R.S. ................................................................ 34
20-20
Procedures for review of licensing applications; denial or issuance of restricted licenses .................. 35
Administration
30-1
Deleted 2/14/2002
30-2
Release of Investigatory File Information to Hospitals or Manage Care Entities ............................... 36
30-3
Release of Investigatory File Information to Professional Review Committees ................................ 37
30-4
Clarification of the Requirements of Section 12-36-118.5, C.R.S., regarding the reporting of physical
and mental illness and conditions (Re-located to 10-27)
30-5
Release of Active Complaint and Investigatory Information to Other State, Canadian or U.S Territorial
Licensing Boards ........................................................................................................... 38
30-6
Release of Investigatory File Information for Law Enforcement and Criminal Justice Purposes ............ 39
30-7
Release of Active Complaint and Investigatory Information to Physician Training Programs ............... 40
30-8
Release of Information from Application Files ....................................................................... 41
30-9
Public Disciplinary and other Board Action Documents ............................................................. 42
30-10
Delegation of Authority .................................................................................................. 44
Practice Policies, Statements & Guidelines
40-1
Repealed 1/01/11
40-2
Guidelines for Discharging a Patient ................................................................................... 46
40-3
Policy Statement Concerning the Provider/Patient Relationship ................................................. 47
40-4
Repealed 11/8/01
40-5
Repealed 11/8/01
40-6
Repealed 12/16/16- Guidelines Regarding the Treatment of Terminally Ill Patients
40-7
Guidelines Pertaining to the Retention and Release of Medical Records........................................ 48
40-8
Guidelines for Departure from a Medical Practice .................................................................. 50
40-9
Guidelines for Prescribing for Unknown Patients .................................................................... 52
40-10
Treating Partners of Patients with Sexually Transmitted Infections ............................................. 53
40-11
Sale of Products in Physicians' Offices ................................................................................. 54
40-12
Office-Based Surgery and Anesthesia .................................................................................. 55
40-13
Use of Alcohol and Other Mind-Altering Substances While On-Call ............................................... 59
40-14
Repealed 05/13/04
40-15
Repealed 1/01/11
40-16
Repealed 1/01/11
40-17
Guidelines Regarding Practice Coverage Outside of Normal Office Hours ...................................... 60
40-18
Self-Treatment and Treatment of Family Members and Others with whom Significant Emotional
Relationships Exist ........................................................................................................ 62
40-19
Use of Lasers to Provide Medical Services ............................................................................ 63
40-20
Repealed 2/17/11
40-21
Repealed 2/17/11
40-22
Repealed 2/17/11
40-23
Repealed 5/19/11
40-24
Clarifying the Scope of Practice of Physician Assistants ........................................................... 64
40-25
Sexual Misconduct Statement and Policy ............................................................................. 65
40-26
Policy For Prescribing and Dispensing Opioids ....................................................................... 68
40-27
Guidelines for the Appropriate Use of Telehealth Technologies in the Practice of Medicine ............... 80
40-28
Policy Regarding Recommendations for Marijuana as a Therapeutic Option ................................... 85
40-29
Board Actions to Protect the Public related to Drug Diversion and Impaired Licensees ...................... 89
DISCIPLINE & ENFORCEMENT
10-1
Protocol 30-Day Letters
Date Issued:
Date(s) Revised:
1/20/94
3/27/97; 5/15/03; 11/13/03; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To authorize staff to initiate 30-day letters upon receipt of specific types of
information.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that upon receipt of a report or other
notification addressing an issue within the jurisdiction of the Board from one of the entities generally
described below; staff shall establish a numbered complaint file and shall issue a 30-day letter to the
involved licensees.
In the event the written notification from the reporting entity does not include a substantive account of
the potential unprofessional conduct issues, Board staff shall correspond with the reporting entity and
request additional information for review by the Board. Staff may, in its discretion, bring the information
to the attention of an Inquiry Panel for review and further direction prior to issuance of the 30-day
letter.
Upon receipt of the 30-day letter response, the original report, the response and any other information
which has been collected shall be forwarded to the appropriate panel for review in the standard
manner.
This policy shall apply to reports or notifications forwarded to the Board by or on behalf of the following:
1. Hospitals/HMOs;
2. Government agencies including, but not limited to, Colorado Departments of: Regulatory
Agencies, Corrections, Public Health and Environment, Public Safety, and Health and
Human Services; United States (“US”) Drug Enforcement Administration, US Departments
of: Health and Human Services, Justice, Defense or its component services, and the
Veterans Administration; or, other law enforcement agencies;
3. Other State medical boards, NPDB, or FSMB;
4. Professional/specialty societies;
5. Miscellaneous sources with generally accepted credibility such as CPHP, CPEP, allied
health providers, residency directors; professional liability insurers, Federal or State
Courts; or,
6. Any other individual submitting a signed complaint.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-3
Retention of Letters of Concern
Date Issued:
Date(s) Revised:
1/1/96
11/08/01; 7/01/10; 2/19/15 (effective 4/1/15)
Purpose:
To define the retention period for Letters of Concern.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that complaint files in which a letter of
concern has been issued to the licensee will be retained by the Board for a period of 5 years.
After five years from the date of the letter of concern, the file will be treated as a standard dismissal and
disposed of in the customary fashion. If the physician has other active cases pending at the end of the
five year retention period, the letter of concern may be kept for a longer period of time at the discretion
of Board staff.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-5
Disciplinary Actions Taken Against Colorado Licensees Holding Expired or
Inactive Licenses By Other State Medical Boards or Governmental Agencies
Date Issued:
Date(s) Revised:
2/15/96
11/08/01; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify action to be taken by Board staff when disciplinary actions are
received
POLICY: It is the policy of the Colorado Medical Board (“Board”) that no investigation will be initiated in
those instances in which the Board receives a report of disciplinary action from another state medical
board or governmental agency involving a physician, physician assistant, or anesthesiologist assistant
who holds a Colorado license that is either expired or inactive.
At such time as the Colorado physician, physician assistant, or anesthesiologist assistant chooses to
apply for reinstatement or reactivation of his Colorado license, it shall be the policy of the Board to
inquire with the Federation of State Medical Boards as to the applicant’s disciplinary history. If the
Federation report indicates that the applicant has had disciplinary action taken by another medical
received
board or governmental agency, normal procedures will be followed to obtain information regarding the
nature and extent of the action taken. This information shall be presented to the Board in the
customary fashion.
Exceptions to this policy may occur at the discretion of the Board when the conduct at issue is such that
immediate action is warranted.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-6
Orders to CPHP
Date Issued:
Date(s) Revised:
5/16/96
5/11/06; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify the Board’s position regarding Orders to CPHP
POLICY: In conformity with its statutory purpose to protect the people of the state of Colorado, the
Colorado Medical Board ("Board") finds that it has reasonable cause to believe that licensees meeting
one or more of the following criteria are unable to practice medicine with reasonable skill and safety
to patients because of a condition described in section 12-36-117(1)(i) or (o), C.R.S:
1. Criminal charges involving drugs, alcohol, domestic violence, assaultive behavior or illegal use
of weapons;
2. Self-report to the Board of a mental or physical illness or condition, or substance use problem
that has impacted or may impact the licensee’s practice as a physician, physician assistant,
or anesthesiologist assistant;
3. Report from CPHP that licensee has violated CPHP Safe-Haven provisions as set forth in Board
Policy 10-27, part B;
4. Report by employer or peer review committee of mental or physical illness or condition, or
substance use issues that has impacted or may impact the licensee’s practice as a physician,
physician assistant, or anesthesiologist assistant;
5. Report that licensee may not be determining or maintaining appropriate practitioner/patient
boundaries: or,
6. Upon credible information that licensee may be a danger to self or others.
Therefore, it shall be the policy of the Board to order such licensees to the Colorado Physician Health
Program ("CPHP") for a mental and/or physical evaluation pursuant to section 12-36-118(9)(a), C.R.S.
The Board delegates to the Program Director, or acting Program Director, the authority to issue such an
order in aforementioned instance numbers 1 and 2.
The Board delegates the authority to issue such orders in aforementioned instance numbers 3, 4, 5, and
6, to the Program Director or acting Program Director, in consultation with the Panel Chair, Board
President, or a quorum of the Inquiry Panel, if deemed necessary by the Panel Chair or Board President.
The Board will review other circumstances under which an order to CPHP for evaluation pursuant to
section 12-36-118(9)(a),C.R.S., is appropriate on a case-by-case basis.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-8
Anonymous Complaints
Date Issued:
Date(s) Revised:
8/15/96
11/08/01; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify the Board’s position regarding consideration of anonymous
complaints define the retention period for the above mentioned cases
POLICY: It is the policy of the Colorado Medical Board (“Board”) to discourage anonymous complaints.
The Board will not automatically investigate anonymous complaints. Instead, the Board will review such
complaints on a case-by-case basis to determine if an investigation is warranted.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-9
Enforcement of Injunctive Actions
Date Issued:
Date(s) Revised:
5/11/06
7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To authorize the referral of case for contempt proceedings
POLICY: It is the policy of the Colorado Medical Board (“Board”) that upon information that an individual
or entity has violated an Order of Injunction issued by a court of competent jurisdiction against that
individual or entity pursuant to section 12-36-129, C.R.S., the Board specifically authorizes the Program
Director to refer such matter directly to the Office of the Attorney General for initiation of contempt
proceedings.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-10
Investigative Subpoena Enforcement
Date Issued:
Date(s) Revised:
10/13/94
7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify the authority to request subpoena enforcement
POLICY: It is the policy of the Colorado Medical Board (“Board”) that should a subpoena need to be
enforced pursuant to the Medical Practice Act or the Administrative Procedure Act during the course of
an investigation; the Board specifically authorizes the Program Director to refer such matter directly to
the Office of the Attorney General for enforcement.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-15
Eligibility to Serve as Practice Monitor
Date Issued:
Date(s) Revised:
11/13/97
7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify the requirements to serve as a practice monitor for a physician
under probation with the Board
POLICY: It is the policy of the Colorado Medical Board (“Board”) that a physician must meet the
following criteria in order to serve as a practice monitor for a practitioner under probation
(“Respondent”) with the Board:
1. Currently holds an active unrestricted license issued by the Colorado Medical Board;
2. Not currently under investigation by the Board or the subject of current disciplinary
proceedings;
3. Currently practicing as a physician;
4. Have no financial interest in the Respondent’s practice; and
5. Knowledgeable in the Respondent’s area of practice and practice setting.
Should a Respondent nominate a practice monitor who does not meet these criteria, Board staff will
notify the Respondent that a new practice monitor must be nominated within 30 days. The tolling
provision of a Stipulation or Final Agency Order may be invoked during such time as Respondent’s
practice is not monitored.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-16
Subpoena of Plaintiff’s Records in Malpractice Cases
Date Issued:
Date(s) Revised:
5/20/99
7/1/10; 2/17/11; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance regarding the subpoena of plaintiff’s expert witness
reports and other pertinent records
POLICY: It is the policy of the Colorado Medical Board (“Board”) that staff will subpoena any available
expert witness reports and other pertinent records form the plaintiff’s attorney in all medical malpractice
cases reported to the Board wherein the settlement or judgment was $400,000 or more.
The Inquiry Panels have the discretion to subpoena records in other malpractice cases involving lesser
settlements or judgments on a case-by-case basis.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-17
Process for Handling Complaints Involving Board Members or Licensees with
Ongoing Formal Relationships with the Board.
Date Issued:
Date(s) Revised:
8/19/99
11/8/04; 8/20/09, 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide written notice regarding the process by which specific types of
complaints against current Board members, licensees who have served on the
Board within the past five years, or licensees who have an ongoing formal
relationship with the Board will be handled. The purpose of this policy is to
assure the integrity of the disciplinary process and prevent any appearance of
bias or preferential treatment
.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that any signed complaint received by
the Board against a current licensee who is a member of the Board, or one who has served on the Board
within the past five years, or a licensee who has an ongoing formal relationship with the Board will be
handled as follows:
•
If the complaint alleges a violation of the Medical Practice Act or Board Rules, the complaint
will be sent to the Office of Investigations within the Division of Professions and Occupations
for a formal investigation.
•
If the complaint alleges substandard practice, the Office of Investigations will also have
the case reviewed by an independent consultant selected by the Office of Investigations.
•
If the complaint alleges sexual boundary violations, allegations of substance abuse or
allegations of a physical or mental illness or condition, the licensee will be required to undergo
evaluation by CPHP, or by a qualified healthcare provider selected by the Office of
Investigations.
Upon completion of the investigation and/or evaluation, the report will be referred to the Inquiry Panel
for appropriate action.
•
If the complaint alleged sexual boundary violations, substance abuse, or physical or mental
illness or condition which is substantiated by report from the Office of Investigations and, the
Office of Investigations has not already done so, the Panel shall require the licensee to undergo
evaluation by CPHP or a qualified healthcare provider selected by the Office of Investigations.
•
If the complaint is against a current board member, the complaint will be assigned to the Inquiry
Panel on which the Board member does not serve. If the complaint is against the current Board
President/Chair, he or she shall recuse from all discussions regarding the complaint and
physically leave the meeting room during these discussions.
All other customary procedures for the handling of a complaint by the Board will apply. These include,
but are not limited to, issuance of a 30‐day letter, notification to the licensee and complainant of Board
decisions, and the confidentiality of the complaint and investigation as provided by the Medical Practice
Act.
Anonymous complaints filed against a current licensee who is a member of the Board or one who has
served on the Board within the past five years, or a licensee who has an ongoing formal relationship
with the Board will be evaluated by the Panel on a case-by-case basis and in accordance with the
Board’s policy regarding anonymous complaints.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-19
Scope of Investigations
Date Issued:
Date(s) Revised:
11/18/99
7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance regarding expanding the scope of investigation.
POLICY: It is the policy of the Colorado Medical Board (“Board”) to allow an investigator to expand the
scope of an investigation when warranted. Such expansion may include, but not be limited to;
investigation of the care provided to patients other than those originally referred for investigation or the
investigation of other possible Medical Practice Act violations which were not known to the Inquiry Panel
at the time the case was referred for investigation.
Should the investigator determine that expansion of the scope of an investigation is warranted, the
investigator must notify the Board's Program Director prior to expansion of the investigation. Should the
Program Director have any concerns regarding the expansion of the investigation, the matter will be
brought to the appropriate Inquiry Panel for consideration.
2017-01-02
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DISCIPLINE & ENFORCEMENT
10-20
Supplemental Informal Complaints
Date Issued:
Date(s) Revised:
8/2/04
7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance regarding the issuance of a supplemental informal
complaint pursuant to section 12-36-118(4)(a)(1), C.R.S.
POLICY: It is the policy of the Colorado Medical Board (“Board”) to issue a supplemental informal
complaint pursuant to section 12-36-118(4)(a)(I), C.R.S., under the following circumstances:

Where an investigation has been expanded to include the care of patients who were not
included in the original informal complaint, unless the Panel has decided that there is no
reasonable cause to warrant further action with respect to those additional patients; or,

Where an investigation reveals possible additional unprofessional conduct of a different nature
than that of which the licensee has already had the opportunity to respond to the Panel, unless
the Panel has decided that there is no reasonable cause to warrant further action with respect
to the additional unprofessional conduct.
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DISCIPLINE & ENFORCEMENT
10-21
Practicing Monitoring Compliance Policy
Date Issued:
Date(s) Revised:
4/14/05
10/13/05; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance regarding the enforcement of the practice monitoring
provisions of a Stipulation or Final Agency Order.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that Board staff will promptly
notify a licensee whose practice monitoring report is late that the licensee must come into
compliance with the terms of the Stipulation or Final Agency Order within 14 days. If the licensee
does not come into compliance, the Program Director, in consultation with the Panel Chair or
President, will determine whether imposition of a suspension pursuant to section 12-36-118
(5)(g)(IV), C.R.S, is warranted.
Non-compliance issues will be reported by Board staff to the Inquiry Panel and the
Office of the Attorney General as appropriate. The Panel may determine that additional
disciplinary proceedings are warranted due to a licensee's non- compliance with a Stipulation or Final
Agency Order.
Practice monitors whose reports are not timely and complete on at least two occasions shall be
deemed to have failed to perform their duties as a practice monitor and may be terminated as the
practice monitor at the discretion of the Regulatory Compliance Program Manager or Program
Director.
If the physician is terminated as the licensee's practice monitor, the licensee shall be instructed to
nominate a new practice monitor within 30 days of the date of notification. A licensee's
probationary period shall be tolled pursuant to the terms of the licensee's Stipulation or Final Agency
Order.
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DISCIPLINE & ENFORCEMENT
10-23
Process for Handling Initial Decisions
Date Issued:
Date(s) Revised:
2/19/15 (effective 4/1/15)
Purpose:
To provide clarity regarding the process for handling Initial Decisions rendered
by an Administrative Law Judge (ALJ)
POLICY:
It is the policy of the Colorado Medical Board (“Board”) that any Initial Decision of an
Administrative Law Judge (“ALJ”) from the Office of Administrative Courts (“OAC”) will be
appropriately served with the approved Board Procedural Order Regarding Review of Initial Decision
(“Order”) upon the parties to the case before the Board. The Board delegates authority to the Program
Director, or his/her designee, to issue such procedural orders for the Board.
The Board further authorizes the Program Director or acting Program Director, to rule on motions for
continuances and motions for extensions of time for filing briefs or pleadings, upon a showing of good
cause.
For the purpose of this policy, good cause may include, but is not limited to: unavailability of counsel
or a party to file briefs or pleadings or to appear for a scheduled hearing due to a preexisting obligation
that cannot reasonably be altered; death or incapacitation of a party or an attorney for a party; a
court order staying proceedings or otherwise necessitating an extension or continuance; entry or
substitution of an attorney for a party a reasonable time prior to the hearing, or a showing that more
time is clearly necessary to complete the scheduled briefing or to prepare for the hearing. Good cause
normally will not include failure of an attorney or a party to timely prepare for the hearing.
The Board authorizes the Program Director, or acting Program Director to determine other motions in
consultation with the Hearings Panel Chair or, by a quorum of the Hearings Panel if deemed necessary
by the Hearings Panel Chair.
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DISCIPLINE & ENFORCEMENT
10-24
Special Appearance Before the Inquiry Panel
Date Issued:
Date(s) Revised:
2/19/15 (effective 4/1/15)
Purpose:
To clarify the Board’s position regarding “special appearances” before the
Inquiry Panel
POLICY: It is the policy of the Colorado Medical Board (“Board”) that appearances before the Inquiry
Panel by licensees or their counsel other than those hearings expressly set forth in statute or regulation
are discouraged. Examples of such hearings include, but may not be limited to, Pre-suspension or Postsuspension hearings.
In limited circumstances, the Inquiry Panel may, in its discretion, permit a presentation to the Panel by
a licensee upon good cause shown. For example, a licensee involved in a disciplinary investigation,
who has elected to enter into an interim practice agreement in lieu of suspension, may request to
make a special appearance before the Panel. The licensee would have to support his/her request with
good cause for the appearance. The Panel will only permit such presentation upon written request
detailing the reason for the presentation and the issues to be discussed.
The Panel reserves the right to deny any request for presentation or to limit the issues presented. If
such request is granted, the presentation shall be limited to those issues set forth in the request or as
limited by the Panel. Any deviation from these issues may be grounds for termination of the
presentation. The licensee has the right to have legal counsel at the presentation.
The Board authorizes the Program Director, in consultation with the Board President, Panel Chair, or a
quorum of the Panel, if deemed necessary by the President or Panel Chair, to determine good cause, to
grant or deny the request, and to limit the issues presented as necessary.
The Medical Practice Act and the Administrative Procedure Act provide a forum for licensees to be
heard during disciplinary proceedings. As such, special appearances as described herein will not be
utilized as a forum to determine the merits of a case once formal disciplinary proceedings have been
initiated.
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DISCIPLINE & ENFORCEMENT
10-25
Issuance of Letters of Concern for certain Criminal Convictions
Date Issued:
Date(s) Revised:
5/16/96
Purpose:
5/11/06; 7/1/10, 2/19/15 (effective 4/1/15)
To clarify the Board’s position regarding the issuance of Letters of Concern for
certain criminal charges
POLICY: It is the policy of the Colorado Medical Board ( “Board”) that the Board will, at a minimum,
issue a Letter of Concern to any licensee with a conviction for driving under the influence (DUI),
driving while ability is impaired (DWAI), or domestic violence. The CPHP evaluation of the licensee,
as discussed in Policy 10-6, will be instrumental in determining whether a letter of concern is
sufficient or the Board should consider more serious action.
As used in this policy, the word "conviction" includes a judgment, guilty plea, a plea of no contest or
nolo contendere, or a deferred judgment and sentence.
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DISCIPLINE & ENFORCEMENT
10-27
Reporting Physical and Mental Illnesses or Conditions to the Board
Date Issued:
Date(s) Revised:
8/9/10
Purpose:
2/19/15 (effective 4/1/15)
To clarify terms and provide guidance regarding the reporting of physical and
mental illnesses or conditions to the Board as required by Section 12-36-118.5,
C.R.S.
POLICY: Section 12‐36‐118.5, C.R.S. and Board Rule 295 apply to all Board licensees holding an active
Colorado license, with or without conditions or restrictions including those licensees holding “Pro Bono”
“Distinguished Foreign Teaching Physician” and Reentry licenses. Physicians holding a Physician Training
License and working under the supervision of a licensed physician need not comply with the reporting
requirements under Rule 295 provided that the physician training licensee is in compliance with section
12‐36‐122, C.R.S The Colorado Medical Board (“Board”) interprets terms used in section 12-36-118.5(1),
C.R.S., as follows:
A.
“Renders the licensee unable to practice medicine or practice as a physician assistant or
practice as an anesthesiologist assistant with reasonable skill and safety to patients”: The
purpose of this reporting requirement is to assure that those licensees with a physical or
mental illness or condition have made appropriate accommodations to his or her practice
as are reasonable to provide safe patient care. The standard for requiring reporting is
whether a reasonable licensee would conclude that the physical or mental illness or
condition impacts, or is likely to impact, the licensee’s ability to perform a medical service
with reasonable skill and safety to patients. It is NOT the purpose of this reporting
requirement to compel licensees to report illnesses or conditions that do not impact the
licensee’s ability to perform medical services with reasonable skill and safety, or are not
likely to do so even if the condition progresses, relapses or otherwise worsens.
1. The following are illustrative of illnesses or conditions that DO NOT need to be
reported:
a. A physical or mental illness or condition that is acute and self-limited or is
stable and controlled by treatment and, as such, a reasonable physician,
physician assistant, or anesthesiologist assistant would conclude that such
illness or condition, with such treatment, does not impact the licensee’s
ability to perform a medical service with reasonable skill and safety to
patients. Examples of illnesses or conditions that may be subject to successful
treatment include but are not limited to: appendicitis, diabetes, coronary
heart disease, and depression.
b. A physical or mental illness or condition that would impact the licensee’s
ability to perform a medical service with reasonable skill and safety to
patients but for which the licensee has voluntarily ceased, modified or
otherwise altered his or her practice to accommodate the illness or condition
so that a reasonable physician, physician assistant, or anesthesiologist
assistant would conclude that the impact to patients has been eliminated and
the licensee is able to perform medical services with skill and safety to
patients. Examples include, but are not limited to: ceasing surgical practice
for a broken arm until full function returns, limiting practice hours to reduce
the physical demands of a longer work day, or a voluntary leave of absence
from work while undergoing chemotherapy.
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2. The following are illustrative of illnesses or conditions that MUST be reported:
a. Any physical or mental illness or condition that results in the licensee
ceasing, limiting or otherwise altering practice as a result of a requirement
imposed upon the licensee by an employer, practice group, payor, hospital
or other health facility. Examples include but are not limited to: a hospital
requiring a licensee to consult with another licensee for all patients
admitted, restricting or placing conditions on the licensee’s ability to
perform specific surgical procedures, or restricting or placing conditions on
the licensee’s role in procedures, such as allowing the licensee only to first‐
assist or not allowing the licensee to operate without another licensee
assisting in the procedure.
b. Any physical or mental illness or condition that a reasonable licensee would
conclude results or is likely to result, in the licensee failing to meet generally
accepted standards of practice. For example, obstructive sleep apnea which
could result in sleeping through calls or pages or falling asleep while providing
medical services.
B.
“Shall notify the board of the illness or condition”: The purpose of this reporting
requirement is to ensure that a licensee with a physical or mental illness or condition is
able, without being subject to disciplinary proceedings, to appropriately manage that
illness or condition such that the licensee can continue to perform medical services with
reasonable skill and safety to patients. Pursuant to section 12‐36‐123.5, C.R.S., the Board
is authorized and required to select one or more peer health assistance programs to
evaluate the extent of physical or mental illness or conditions, refer the licensees for
appropriate treatment, and monitor the licensees to assure compliance with treatment
requirements so that the licensee is able to practice with skill and safety. The Board’s peer
health assistance program pursuant to 12‐36‐123.5, C.R.S., is the Colorado Physician
Health Program (“CPHP”). Therefore, a licensee who reports his or her physical or mental
illness or condition to CPHP and complies with all recommendations made by CPHP shall be
deemed to have notified the Board of the illness or condition for purposes of compliance
with Section 12‐36‐118.5, C.R.S.
The Board encourages early reporting to CPHP of any physical or mental illness or condition that a
reasonable licensee would conclude is likely to impact the licensee’s ability to perform a medical
service with reasonable skill and safety to patients should the condition progress, relapse, or worsen.
The Board strongly encourages such early reporting to CPHP when the physical or mental illness or
condition is likely to impair cognition or judgment, even if such illness or condition has not yet caused
impairment but could do so should it progress, relapse or otherwise worsen.
It is the Board’s expectation that a licensee who habitually or excessively uses or abuses alcohol, a
habit‐forming drug, or a controlled substance as defined in Section 12‐22‐303(7), C.R.S., shall seek
assistance from CPHP. Such licensees are not eligible to enter into a confidential agreement with the
Board pursuant to Section 12‐36‐118.5, C.R.S. A licensee who habitually or excessively uses or abuses
alcohol, a habit‐forming drug, or a controlled substance as defined in Section 12‐22‐303(7), C.R.S.,
who comes to the attention of the Board, may be subject to discipline as set forth in the Medical
Practice Act.
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20-2
Reporting of Applicants to the Federation of State Medical Boards
Date Issued:
Date(s) Revised:
2/15/96
2/18/99; 5/20/10; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance regarding when to file reports with the Federation of
State Medical Boards for denied, conditional or withdrawn applications.
To clarify the Board’s position regarding the issuance of administrative or
POLICY: It is the policyrestricted
of the licenses
Colorado Medical Board (“Board”) that applicants whose
applications have been denied by the Board will be reported to the Federation of State Medical
Boards (“FSMB”) in the customary fashion. The report of denial shall be filed with the FSMB upon
the expiration of the appeal period.
It is also the policy of the Board that the Board will file reports with the FSMB for all applicants
who withdraw their application upon a denial, or the granting of a license subject to conditions
based on a finding of unprofessional conduct as defined in section 12-36-117, C.R.S.
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20-4
Issuance of Administrative or Restricted Licenses
Date Issued:
Date(s) Revised:
5/15/97
11/14/02; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify the Board’s position regarding the issuance of administrative or
restricted licenses
POLICY: It is the policy of the Colorado Medical Board (“Board”) that, if circumstances warrant, a
restricted or limited license may be issued to an applicant.
The Board recognizes the necessity of issuing licenses which sometimes limit licensees to
administrative medicine or only certain aspects of clinical practice; however, the Board will not
consider issuance of, nor will it issue, a license which restricts the licensee from performing all acts
constituting the practice of medicine, practice as a physician assistant, or practice as an
anesthesiologist assistant.
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20-5
Review of International Medical Schools
Date Issued:
Date(s) Revised:
5/15/97
11/14/02; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify the Board’s review process regarding schools not approved
by the Liaison Committee for Medical Education (“LCME”) or the American
Osteopathic Association (“AOA”) for purposes of complying with the
provisions of sections 12-36-107.6,12-36-102.5(3) and 12-36-107, C.R.S.
POLICY: This Colorado Medical Board (“Board”) policy applies to any applicant who graduated from a
school that is not approved by the Liaison Committee for Medical Education (“LCME”) or the American
Osteopathic Association (“AOA”), hereinafter referred to as “Applicant.”
SPECIALTY BOARD CERTIFIED APPLICANTS
If an Applicant possesses a current specialty board certification conferred by the American Board of
Medical Specialties or the American Osteopathic Association (“Board Certified”), the Board need
not, in its discretion, pursue further investigation of the Applicant’s medical school. Instead, the
Applicant's qualifications will be reviewed pursuant to section 12-36-107.6(1), C.R.S., including, but
not limited to, the requirement that the Applicant complete three years of postgraduate clinical
training approved by the Board.
APPLICANTS WHO ARE NOT BOARD CERTIFIED
If the Applicant is not Board Certified, the Board will conduct its own investigation of the
Applicant's medical school pursuant to section 12-36-102.5(3), C.R.S. Such investigation shall
include, but not be limited to, the following:
1. A review of the Applicant’s responses to the required International Medical
Graduate Questionnaire (“questionnaire”);
2. A determination as to whether the Applicant’s medical school is on the list of
medical schools approved by the Medical Board of California;
3. A determination as to whether the Applicant’s medical school is on the list of
medical schools accredited by the Caribbean Accreditation Authority for Education
in Medicine and other Health Professions (“CAAM-HP”);
4. A review of the Applicant’s test scores on the United States Medical Licensing
Examination (“USMLE”) or the Comprehensive Osteopathic Medical Licensing
Examination (“COMLEX”); or,
5. Copies of all clinical clerkship and residency rotation evaluations only if:
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a.
The medical school is not on the list of schools approved by the Medical
Board of California;
b.
The medical school has been denied accreditation by CAAM-HP or is on its
provisional or pending accreditation list;
c.
The Applicant’s responses to the questionnaire are not satisfactory to the
Board; or
d.
The Board has concerns regarding test scores.
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If, after investigation, the Board approves the Applicant's medical school pursuant to section 12-36102.5(3), C.R.S., the Applicant must meet all other licensure requirements as set forth in section
12-36-107, C.R.S, and must have completed three years of postgraduate clinical training approved
by the Board.
Board staff is hereby delegated the authority to approve those applicants who meet the criteria set
forth in this policy.
The Board's approval of a medical school pursuant to this policy is limited to the current Applicant
under review and shall not be construed as a blanket approval of the medical school for any other
graduate/applicant.
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20-6
Clarification of the Continued Competency Requirement with Respect
to the Licenses Restricted to the Practice of Administrative Medicine
Date Issued:
Date(s) Revised:
5/15/97
11/14/02; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide clarification regarding the continued competency requirements
for licenses restricted to administrative medicine
POLICY: It is the policy of the Colorado Medical Board (“Board”) that while the practice of
administrative medicine constitutes the practice of medicine, a physician whose practice has been
limited to administrative medicine must comply with sections 12-36-116(1)(d), 24-34-102(8)(d)(II) or
12-36-137(5), C.R.S., and Board Rule 120 in order to obtain an unrestricted license.
A physician whose practice has been limited to administrative medicine may obtain an active but
limited license to engage in a similar type of administrative medicine without complying with the
aforementioned continued competency requirements. Such physicians must comply with all other
licensure requirements.
For purposes of this policy, the practice of administrative medicine is defined as a practice that does
not involve patient contact or the administration of or interpretation of patient tests, evaluations or
data for the purpose of furthering individual patient care. The practice of administrative medicine
may include but need not be limited to the prospective authorization of medical care and oversight
of physician and related services in long-term care facilities, health maintenance organizations,
health insurance plans, hospitals, and group practices.
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20-9
Physician Assistants Required to Register Primary Physician Supervisor
within One Hundred Eighty (180) Days of Active Licensure
Date Issued:
Date(s) Revised:
2/10/00
8/9/01; 7/1/10; 5/19/11; 2/19/15 (effective 4/1/15)
Purpose:
Physician Assistants Required to Register Primary Physician Supervisor within
One Hundred Eighty (180) Days of Active Licensure
POLICY: Physician assistants in an active licensure status will be allowed one hundred eighty (180) days
from either the date of original licensure, reinstatement, reactivation, or from the date their primary
physician supervisor rescinds supervision, to register a new primary physician supervisor. Failure to do
so will result in the active license being placed in an inactive status.
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20-11
Reinstatement of Expired Licenses
Date Issued:
Date(s) Revised:
8/10/00
8/09/01; 5/16/02; 5/20/10; 7/1/10; 5/19/11; 8/19/11; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance regarding the reinstatement of expired licenses and
potential consequences for practicing on an expired license.
POLICY: Licenses issued pursuant to the Colorado Medical Practice Act expire if not timely renewed.
See sections 12-36-123 and 24-24-102(8), C.R.S. A Licensee is not authorized to practice with an
expired license and shall immediately cease their professional practice until their license has been
reinstated. Expired licenses may be reinstated by submitting an application for reinstatement.
The Colorado Medical Board (“Board”) recognizes the importance of timely license renewals to
ensure continuity of patient care and to confer clear regulatory oversight.
To minimize the
impacts of failing to timely renew a license, the Board authorizes the Program Director, or his/her
designee, to reinstate expired licenses when a complete application is submitted with the
appropriate fees, and no issues are presented requiring Board review.
Staff will not reinstate licenses when there is reason to believe that an Applicant practiced with an
expired license. In these cases, staff will present the reinstatement application and available
information for Licensing Panel review. If the Licensing Panel determines that an Applicant
practiced with an expired license, the Licensing Panel may reinstate the Applicant's license subject
to the imposition of a fine for each month the Applicant practiced with an expired license.
Alternatively, the Licensing Panel may take other action as it deems appropriate to the Applicant's
specific circumstances.
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20-12
Reactivation of Inactive Licenses
Date Issued:
Date(s) Revised:
8/10/00
8/9/01; 5/16/02; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance regarding reactivation of an inactive license when the
licensee has been practicing with an inactive license
POLICY: Pursuant to section 12-36-137(5), C.R.S., a licensee who wishes to resume practice must file
an application to reactivate the license.
It is the policy of the Colorado Medical Board (“Board”) that the Program Director, or his/her
designee, is authorized to administratively reactivate a license if all documentation is in order and no
issues arise during the application process which would require Board review.
An applicant who was unknowingly practicing with an inactive license will be referred by staff to an
Inquiry Panel for investigation. If the investigation produces evidence indicating that the licensee
unknowingly practiced with an inactive license, the Inquiry Panel may issue a letter of concern to the
licensee.
Staff will present for Licensing Panel review those applicants for reactivation who appear to have
been knowingly practicing as a physician, physician assistant, or anesthesiologist assistant in
Colorado with an inactive license. If it appears to the Licensing Panel that the licensee has knowingly
been practicing with an inactive license, the Licensing Panel shall defer action on the pending
application and refer the matter to an Inquiry Panel for investigation. If the investigation produces
evidence indicating probable cause to believe that the licensee knowingly practiced with an inactive
license, the Panel may issue a letter of admonition to the licensee, or may take other disciplinary
action as deemed appropriate.
If the Inquiry Panel finds mitigating circumstances which, in the opinion of the Panel, make issuance
of a letter of admonition unwarranted, such mitigating factors shall be documented in the
investigatory file.
It is also the position of the Board that physicians, physician assistants and anesthesiologist assistants
must immediately cease practice upon learning that their license is inactive. Further, the physician,
physician assistant, or anesthesiologist assistant shall not return to practice until the license has
been reactivated.
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20-13
Ability of Unlicensed Physician Assistants to Provide Delegated Medical
Services Pursuant to Section 2-36-106(3)(l), C.R.S
Date Issued:
Date(s) Revised:
8/10/00
8/9/01; 11/14/02; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance regarding unlicensed physician assistants providing
delegated medical services pursuant to section 12-36-106(3)(l), C.R.S.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that graduates of physician assistant
programs who have not yet taken the certification examination, and thus, are not qualified for
licensure, may perform delegated medical services pursuant to section 12-36-106(3)(l), C.R.S., until
such time as they have been notified that they have passed the certification exam and are eligible
for a Colorado license.
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20-14
Administrative Approval of Licenses
Date Issued:
Date(s) Revised:
11/1/00
8/9/01; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To authorize staff to administratively approve applicants possessing the
credentials necessary for licensure
POLICY: The Colorado Medical Board (“Board”) delegates to the Program Director, or his/her
designee, the authority to license physician, physician assistant, and anesthesiologist assistant
applicants who successfully meet all requirements. At each meeting, the Licensing Panel will
review, for ratification, the list of administratively approved applicants since the previous month’s
agenda.
In the event of uncertainty as to whether an applicant has met licensure requirements, the
applications will be presented to the Licensing Panel for review.
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20-15
Purging Incomplete Applications
Date Issued:
Date(s) Revised:
5/15/97
11/14/02; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify the Board’s position regarding incomplete applications for licensure
POLICY: It is the policy of the Colorado Medical Board (“Board”) that incomplete applications for
licensure will be held open and active for one year from the date of receipt by the Board. Absent
prior authorization by the Licensing Panel, an applicant’s failure to complete the application within
that time period, will result in the application being purged and the application fee being forfeited.
In the event an applicant is actively working toward completion of an application that is nearing or
has reached the one year date of receipt, the Panel authorizes the Program Director, or his/her
designee to grant an extension of time to complete the application. Should an extension be granted,
the applicant will be required to update any supporting documents containing information which
may have changed since the original submission. Such documents include, but are not limited to:




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FSMB report;
NPDB report;
Letters of reference from current employers; and,
All verifications of licenses held in other states.
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20-16
Criteria to Identify Applications Requiring Board Review
Date Issued:
Date(s) Revised:
5/16/02
11/13/03; 2/9/06, 5/20/10; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance as to those applications requiring review by the Board's
Licensing Panel.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that the following criteria will be
used by staff in determining whether an application must be reviewed by the Board's Licensing Panel:
1. Two or more malpractice settlements or judgments occurring within the
last five years and in which damages were awarded or monies paid. NOTE:
all applications reporting one civil malpractice claim that is pending or has
been settled in the past five years shall be reviewed by the Program Director
prior to licensure and brought to the Licensing Panel for review at the
discretion of the Program Director;
2. Refusal to insure or cancellation of medical liability insurance;
3. Any misdemeanors charges involving drugs, alcohol, or domestic violence
occurring in the last five years;
4. Any felony charges, indictments, convictions, deferred prosecutions,
deferred judgments, irrespective of how long ago it occurred;
5. Any conviction or charge of Driving Under the Influence (“DUI”) or Driving
While Ability Impaired (“DWAI”), alcohol or drug related, occurring within
the last five years;
6. Any disciplinary action taken against the applicant's license by another
medical board or regulatory/government agency irrespective of when that
action occurred;
7. Any applicant who has received three or more non-disciplinary actions from
another medical board, such as a letter of concern, letter of caution, or
letter of guidance;
8. Any applicant who reports that he or she is under investigation by another
state board;
9. Any applicant who reports that he or she has been denied by another
medical board on the basis of conduct which would constitute
unprofessional conduct under Colorado law. NOTE: Any applicant who was
denied licensure in another state for failure to meet the statutory licensure
requirements related to education and training does not require review by
the Licensing Panel;
10. Any "yes" response to the application questions related to mental, physical
or cognitive health conditions which might affect an applicant's ability to
practice safely. Except that reports of situational depression due to
divorce, death in the family, etc., for which the Board has received
confirmation from the applicant's treating physician that the applicant was
treated and the situation resolved satisfactorily, do not require Board
review;
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11. Any limitation, restriction, suspension, revocation, or denial of hospital
privileges, irrespective of when the action occurred. NOTE: hospital
actions relating to administrative issues, that is, actions not related to
quality of care or behavioral issues, do not require review by the Licensing
Panel. An example of this would be a suspension of a physician's license by
a hospital for failure to attend required staff meetings);
12. Any applicant whose L3 form regarding completion of postgraduate training
indicates that the training was not completed satisfactorily if the basis for
the unsatisfactory performance related to patient care issues, physical or
mental health issues or impairment;
13. Any applicant for an original license, or reactivation of a license who has
not been engaged in the practice of medicine for the two-year period
immediately preceding the filing of the application; or,
14. Any applicant for reinstatement of a license, whose license has been
expired for more than two years and who has not been engaged in the
practice of medicine for the two-year period immediately preceding the
filing of the application.
The foregoing criteria are also applicable for physician training license applicants; however, staff
may grant a 60 day training permit to those applicants whose application requires Board review.
Staff retains the authority and discretion to present any application to the Licensing Panel should
staff believe that review of the application is warranted. It is the expectation of the Board that,
when in doubt, staff will present an application for review by the Licensing Panel.
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20-17
Referral of Applicants to the Colorado Physician Health Program for
Evaluation
Date Issued:
Date(s) Revised:
5/16/02
7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide notice of the Board’s requirement for applicant evaluation
POLICY: It is the policy of the Colorado Medical Board (“Board”) that any applicant reporting that he
or she has been charged within the last five years with any offense involving drugs, alcohol,
domestic violence, assaultive behavior, or illegal use of weapons will be required to undergo
evaluation by the Colorado Physician Health Program (“CPHP”).
The CPHP evaluation of the applicant will be informative in determining whether the applicant meets
the statutory qualifications for licensure.
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20-18
Physician Training Programs
Date Issued:
Date(s) Revised:
11/14/02
4/14/05; 10/13/05; 7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To provide guidance regarding the application process for physician training
programs.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that a physician who has matched
into a preliminary designated position as defined below may submit a single application for
participation in the preliminary training program and the subsequent training program.
The applicant must indicate on the application, and the applicant's program director will indicate on
the letter of attestation, both the preliminary program and the subsequent program into which the
applicant has matched.
DEFINITIONS:
Preliminary Designated position. The applicant has matched into a permanent position
after completing the preliminary year(s). This applicant will maintain this license through
the completion of their PG1 and subsequent matched program. The subsequent matched
program has been noted on this letter of attestation and will also be indicated on the
application.
Preliminary Non-designated position. The applicant does not have a designated
permanent position in the current program or another program at time of acceptance.
This applicant will maintain this license for the duration of the PG1 year only and
understands that a match into a subsequent program will require that a new training
license application be filed with the Board and a new training license issued. The
applicant's program director should advise the Board when the applicant exits the
program.
Categorical (permanent) position. This applicant will maintain this license for the
duration of the program, unless such license expires through the normal renewal process
or the applicant exits the program to pursue another area of training. The applicant's
program director should advise the Board when the applicant exits the program.
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20-19
Clarification of the 60-day Rotation Exemption from Licensure/Physician
Training Licensure Requirements Pursuant to section 12-36-106(3)(v),
C.R.S.
Date Issued:
Date(s) Revised:
5/15/03
7/1/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify the "aggregate period not to exceed sixty days" during which
interns, residents and fellows may be exempt from licensure/physician training
licensure requirements pursuant to section 12-36-106(3)(v), C.R.S.
POLICY: As a general rule, any person participating in an approved internship, residency or fellowship
as defined in the Medical Practice Act must have a Colorado medical license pursuant to sections 1236-107 or 12-36-107.6, C.R.S. or must have a Colorado physician training license pursuant to section
12-36-122, C.R.S. However, section 12-36-106(3)(v), C.R.S. provides that no license is required for the
rendering of medical services by any person serving an approved internship, residency, or fellowship as
defined by the Medical Practice Act "for an aggregate period not to exceed sixty days."
It is the policy of the Colorado Medical Board (“Board”) that the "aggregate period not to exceed
sixty days" referenced in section 12-36-106(3)(v), C.R.S. means that a person may serve in an
approved internship, residency or fellowship for a period of 60 days per year without obtaining a
Colorado medical license or a Colorado physician training license. The year as set forth in this policy
will commence on the first day the intern, resident or fellow begins training in Colorado. For
example, if a medical resident begins a 60-day rotation in Colorado on June 1, the resident would not
be able to serve in another internship, residency or fellowship program until on or after June 1 of
the following year, unless the resident obtained a Colorado medical license or a Colorado physician
training license.
The intern, resident or fellow is responsible for assuring compliance with section 12-36-106 (3)(v),
C.R.S. Notwithstanding, it is the responsibility of the training program to ensure that all participants
in the program are in compliance with Colorado law.
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20-20
Procedures for review of licensing applications; denial or issuance of
restricted licenses
Date Issued:
Date(s) Revised:
11/19/09
07/01/10; 2/19/15 (effective 4/1/15)
Purpose:
To clarify the Board’s procedures for reviewing and acting upon license
applications.
Policy: It is the policy of the Colorado Medical Board (“Board”) that an application for an initial
(original) license as a physician, physician assistant, or anesthesiologist assistant or the
reinstatement or reactivation of an existing license will be handled in the following manner:
1. The Board’s Licensing Panel will only consider complete applications. Complete
applications are those that comply with legal requirements found at sections 12-36-111,
12-36-107.4, 12-36-107.2, 12-36-114.3 and 12-36-114.5, C.R.S. and the Board's licensing
application forms available on its website at ,www.dora.state.co.us/medical/index/htm.
Board staff assembles the complete application package as submitted by applicants for
review by the Licensing Panel during its regularly scheduled meetings;
2. Upon its review of a complete application, the Licensing Panel may decide: that it
requires additional information in order to resolve any issues presented in the
application; to grant a license subject to terms of probation; or to deny the application
pursuant to section 12-36-116, C.R.S. Board staff will notify the applicant of the Panel's
decision and, if applicable, the right to timely request a hearing pursuant to section 24-4104(9), C.R.S.;
3. If the applicant timely requests a hearing, board staff will refer the matter to either the
Office of Expedited Settlement or to the Office of Attorney General for further processing
in accordance with the Panel's instructions. The Licensing Panel will not review or
consider an applicant's request for reconsideration. If the applicant requests
reconsideration, such a request will be considered a request for hearing as set forth in
section 24-4-104(9), C.R.S., and staff will refer the matter accordingly; and,
4. The Licensing Panel may consider, at the time of its licensing decision, whether to permit the
applicant to withdraw the application. Such decision shall be within the sole discretion of the
Licensing Panel. The Licensing Panel will delegate the authority to board staff to process any
subsequent withdrawal request, which will be processed in compliance with its decision and Board
Policy 20-2.
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30-02
Release of Investigatory File Information to Hospitals or Managed Care Entities
Date Issued:
Date(s) Revised:
05/15/97
07/01/10; 2/19/15
Purpose:
To provide guidance regarding the release of information to managed care
entities and hospitals upon receipt of an appropriate release from the
licensee.
POLICY: It is the policy of the Colorado Medical Board (“Board”), that upon receipt of an
appropriately executed release by the licensee, staff may provide confirmation of dismissed
complaints to a managed care entity or hospital.. If a complaint was dismissed with a confidential
letter of concern, staff is to confirm only that the complaint was dismissed and is not to disclose
information regarding the letter of concern.
The Board will not release investigatory information regarding dismissed complaints to managed
care entities or hospitals.
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30-03
Release of Investigatory File Information to Professional Review Committees
Date Issued:
Date(s) Revised:
08/14/97
02/10/00; 07/01/10; 02/19/15
Purpose:
To provide guidance regarding release of information to professional
review committees.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that investigatory file information
for a disciplinary action may be provided to a Professional Review Committee designated pursuant to
Section 12-36.5-104(4)(c) or (d), C.R.S., subject to confirmation that the licensee for whom the
committee is requesting information is subject to peer review by the organization. The Program
Director will consult with the Office of the Attorney General prior to release of any such
information.
Patient records and peer review materials will not be released.
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30-05
Release of Active Complaint and Investigatory Information to Other State,
Canadian or U.S. Territorial Licensing Boards
Date Issued:
Date(s) Revised:
2/1/95
5/14/98; 11/08/01; 11/13/03; 4/14/05; 07/01/10, 11/18/10; 2/19/15
Purpose:
To authorize staff to release active complaint information and to transmit
confidential investigatory materials to other licensing boards upon request.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that staff may advise other
state, Canadian or U.S. Territorial medical boards regarding a licensee's complaint history and
complaints currently under investigation.
Upon request from another licensing board, staff may transmit information from the investigatory
and/or hearing file which is normally considered to be confidential pursuant to section 12-36118(10), C.R.S.
Prior to transmittal of this information, Board staff will consult with the Office of the Attorney
General to prevent the release of information that the Board is prohibited from redisclosing or
that is otherwise confidential by law, such as peer review information, documents subject to the
attorney/client or physician/patient privilege, and letters of concern.
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30-06
Release of Investigatory File Information for Law Enforcement and
Justice Purposes
Criminal
Date Issued:
Date(s) Revised:
05/11/06
07/01/10; 02/19/15
Purpose:
To provide notice regarding the Board’s process for reviewing requests for
release of investigatory file information.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that requests from law
enforcement entities or other parties involved in the criminal justice system for release of
information confidential pursuant to Section 12-36-118(10), C.R.S., will be evaluated on a case-bycase basis.
When determining what information, if any, to release pursuant to such requests, the Board will
consider several factors including, but not limited to, whether it believes that the Board's primary
mission of public protection and legal obligations warrant the release of such information.
Prior to transmittal of this information, the Board staff will consult with the Office of the Attorney
General to prevent the release of information that the Board is prohibited from redisclosing or that
is otherwise confidential by law, such as peer review information, documents subject to the
attorney-client or physician/patient privilege, and letters of concern.
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30-07
Release of Active Complaint and Investigatory Information to Residency
Training Programs
Date Issued:
05/18/07
Date(s) Revised:
11/18/10; 02/19/15
Purpose:
To authorize staff to release active complaint information and to transmit
confidential investigatory materials to physician training programs.
POLICY: It is the policy of the Colorado Medical Board (“Board”) that staff will immediately notify
the training program of complaints involving an intern, resident, or fellow who holds either a
license to practice medicine, a training license, or who has applied for a training or medical
license, and is enrolled in or accepted into a training program.
Upon receipt of a complaint or initiation of a complaint by the Board, staff must notify the training
program administrators and the licensed physicians responsible for the supervision of an intern,
resident or fellow in the training program. It shall be the responsibility of the training program to
request further documentation of the nature of any complaint, if that information is desired.
Upon request from the training program, staff may transmit information from the investigatory
and/or hearing file which is normally considered to be confidential pursuant to Section 12-36118(10), C.R.S.
This policy contemplates that staff may consult with the Panel Chair or Board President as necessary
prior to release of information. Prior to transmittal of this information, Board staff will consult as
necessary with the Office of the Attorney General' to prevent the release of information that the
Board is prohibited from redisclosing or that is otherwise confidential by law, such as peer review
information, documents subject to the attorney-client or physician/patient privilege, and letters of
concern.
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30-08
Release of Information from Application Files
Date Issued:
Date(s) Revised:
03/27/95
07/01/10; 02/19/15
Purpose:
To provide guidance regarding the release of information from application
files
POLICY: It is the policy of the Colorado Medical Board (“Board”) that upon written request from an
applicant for a copy of their application file, the entire file shall be provided with the exception of
the following:
1. Letters of reference including, but not limited to, letters from residency programs
indicating whether the applicant had satisfactorily completed the program; and
2. Information that the Board is prohibited from redisclosing or that is otherwise
confidential by law, such as peer review information, documents subject to the attorney
/client or physician/patient privilege, or letters of concern.
It is the policy of the Board that upon written request from a party, other than the applicant, for a
copy of a licensee’s application file, the entire application will be provided with the exception of the
following:
1. Letters of reference including, but not limited to, letters from residency programs
indicating whether the applicant had satisfactorily completed the program;
2. Transcripts;
3. Examination scores;
4. Medical or psychological records concerning the applicant; and,
5. Information that the Board is prohibited from redisclosing or that is otherwise
confidential by law, such as peer review information, documents subject to the attorney
/client or physician/patient privilege, or letters of concern.
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30-9
Public Disciplinary and other Board Action Documents
Date Issued:
Date(s) Revised:
11/18/99
10/31/05; 8/20/09; 7/1/10; 8/15/13; 2/19/15 (effective 4/1/15)
Purpose:
To provide notice as to those documents which the Board considers to be a
matter of public record pursuant to sections 12-36-118(10) and 12-36-132,
C.R.S.
POLICY:
It is the policy of the Colorado Medical Board (“Board”) that documents and
information pertaining to Board matters are classified as follows:
I.
Disciplinary
A. The following documents pertaining to the disciplinary process are a
matter of public record:
1. Final Letters of Admonition issued after July 1, 1993;
2. Stipulations between the Board and a Licensee;
3. Orders of Suspension, including Orders of Summary Suspension;
4. Interim Cessation of Practice and Interim Practice Agreements;
5. Final Board/Agency Orders; and,
6. Final Cease and Desist Orders.
B. The following documents pertaining to the disciplinary process are a matter of public
record unless sealed by an Administrative Law Judge, a court of competent
jurisdiction, the Hearings Panel, the Licensing Panel, or the Board:
1. All pleadings, initial decisions or orders, including any attachments,
exhibits, and transcripts filed or created in relation to a hearing held
pursuant to the Medical Practice Act or the Administrative Procedure
Act; and,
2. All documents contained in the record of an appellate proceeding
following a hearing held pursuant to the Medical Practice Act or the
Administrative Procedure Act.
C. The following documents pertaining to the disciplinary process are not a matter of
public record and are not open for public inspection:
1. Matters sealed by order of an Administrative Law Judge, a court of
competent jurisdiction, a Hearings Panel, a Licensing Panel, or the
Board; and
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2.
II.
Materials supplied in hearings held pursuant to Board Rule 280.
Non-Disciplinary
A. The following non-disciplinary documents are a matter of public record:
1. Licensing Agreements between the Board and licensees; and
2. Non-disciplinary Licensing Stipulation.
B. The following non-disciplinary documents are not a matter of public record and
are not open for public inspection:
1. Confidential Agreements pursuant to section 12-36-118.5, C.R.S.
III.
Unlicensed
A. It is the policy of the Board that the following documents pertaining to the
unlicensed practice of medicine are a matter of public record:
1. Final Cease and Desist Orders;
2. Injunctions/Temporary Restraining Orders; and,
3. Contempt Citations.
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30-10
Delegation of Authority to Enforcement Program Manager,
Program Director, and Section Director
Date Issued:
Date(s) Revised:
10/14/93
2/13/97; 5/14/98; 11/08/01; 02/03/03; 11/13/03; 02/18/10;
07/01/10; 08/19/10; 11/18/10; 02/19/15; 2/18/16
Purpose:
To clarify the authority which has been delegated to Board and Division
Staff
POLICY: The Colorado Medical Board (“Board”) delegates the following authority to the Program
Director or his/her designee:
A. Regulatory Compliance
1. Approve urine interruption waiver requests as recommended by the state’s peer
assistance program.
2. Unless otherwise ordered by the Board on a case-by case basis, approve changes in the
frequency of urine screens as recommended by the state’s peer assistance program.
3. Accept, on the Board’s behalf, practice and treatment monitoring reports and any other
such reports submitted as required by the Stipulation or Final Agency Order, provided
such reports are in compliance with the terms of the Stipulation or Final Agency Order.
4. Terminate Agreements, Suspensions, Stipulations and Final Agency Orders where the
Respondent has complied with all terms of the Orders and no other issues or complaints
are pending before the Board regarding the Respondent.
5. Initiate complaints and issue 30-day letters to physicians currently under Stipulation or
Final Agency Order if, in the opinion of the Program Director, the physician has failed to
comply with any of the terms of his/her Stipulation.
6. Issue and sign Orders of Suspension authorized pursuant to Section 12-36-118(5()(g)IV),
C.R.S., in consultation with the Panel Chair or Board President.
7. Vacate Orders of Suspension authorized pursuant to Section 12-36-118(5)(g)(IV), C.R.S.,
upon showing of compliance with Board Orders.
8. Subject to the terms of the Stipulation or Final Agency Order, approve requests to
inactivate Respondent’s license and toll the Respondent’s probationary period for any
time the Respondent’s license is inactive.
B.
Enforcement and Licensing
1. Upon a showing of good cause, grant an extension of time for Respondent to submit
his/her response to the 30-day or supplemental 30-day letters.
2. Issue and sign Orders of Suspension authorized pursuant to section 12-36-118(9) C.R.S.,
in consultation with the Panel Chair or Board President.
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3. Vacate Orders of Suspension authorized pursuant to section 12-36-118(9),C.R.S., upon
a showing of compliance with Board orders.
4. To deny applications for consideration of a Confidential Agreement authorized by 1236-118.5, C.R.S., when the applicant does not meet the requirements outlined in Board
Rule 295 and Board Policy 10-27.
5. Suspend and reinstate the licenses of practitioners who violate, and subsequently come
into compliance with, the Child Support Enforcement Act as notified by the Colorado
Department of Human Services.
6. Subpoena documents and gather information in order to assist the Board in carrying out
its duties.
7. Sign Letters of Concern, Letters of Admonition, Show Cause Orders, Cease and Desist
Orders, Confidential Agreements, Stipulations and Final Agency Orders, Licensing
Stipulations, Re- entry License Agreements, and other formal actions authorized
by the Board.
8. Coordinate and Conduct Public Stakeholder Meetings.
9. Utilize services of the Office of Investigations as warranted to carry out duties of the
Board.
10. Upon a showing of good cause, and in consultation with Panel Chair or Board President,
grant extensions of time for Respondents to present to the Colorado Physician Health
Program (“CPHP”).
11. Upon successful completion of the Board ordered supervised re-entry program, and in
consultation with the Panel Chair or other member of the Licensing Panel as delegated
by the Panel Chair, convert the Re-entry License to a full unrestricted license to
practice.
C.
Other
1. Perform additional delegated duties as ordered by Board or as authorized in other
Board policies.
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40-2
Guidelines for Discharging a Patient
Date Issued:
Date(s) Revised:
2/13/97
7/1/10; 8/20/15
Purpose:
To set guidelines for the proper discharge of a patient from a
physician’s practice
POLICY: It is the policy of the Colorado Medical Board (“Board”) that the proper discharge of a patient
from a provider’s practice includes the following elements:
•
The discharge is done in writing, via delivery that confirms receipt to the patient, such as
certified mail or hand-delivery.
•
In the discharge letter the provider agrees to provide 15-30 days of emergency
coverage while the patient obtains a new provider.
•
If possible, the provider provides referral information to the patient regarding possible
new providers.
•
Notification in the letter to the patient that patient records will be sent to the new
provider upon receipt of written authorization from the patient.
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40-3
Policy Statement Regarding the Provider/Patient Relationship
Date Issued:
Date(s) Revised:
11/13/97
7/1/10; 8/20/15
Purpose:
To clarify the Colorado Medical Board’s definition of, and position concerning
the provider/patient relationship
POLICY: The Colorado Medical Board (“Board”) adopts the following policy regarding the providerpatient relationship:
The Board defines “Provider” to include licensees regulated by the Board and the “Provider-Patient
Relationship” as the mutual understanding, between a provider and patient, of the shared responsibility
for the patient’s healthcare. This relationship is established when:
A. The provider agrees to undertake diagnosis and treatment of
the patient, and the patient, or a medical proxy for the
patient, agrees to be treated- whether or not there has been
an in-person encounter between the patient and the provider;
and,
B. The provider:
i. Verifies and authenticates the patient’s identity and
location;
ii. Discloses his or her identity and applicable
credential(s) to the patient; and,
iii. Obtains appropriate informed consent after any
relevant disclosures regarding the delivery models and
treatment methods or limitations, including any
special informed consents regarding the use of
telehealth technologies.
A “Provider-Patient Relationship” has not been established when either the identity of the provider is
unknown to the patient or the identity of the patient is not known to the provider.
Further, the Board finds the relationship between a provider and a patient is fundamental, and is not to
be constrained or adversely affected by any considerations other than what is best for the patient. The
existence of other considerations, including financial or contractual concerns is, and must be, secondary to
the fundamental relationship. Prevailing models of medical practice may result in an inappropriate
restriction of the provider’s' ability to practice quality medicine, creating negative consequences for the
patient. It is the expectation of the Board that providers take those actions they consider necessary to
assure that the procedures in question do not adversely affect the care that they render to their patients.
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40-7
Guidelines Pertaining to the Retention and Release of Medical Records
Date Issued:
Date(s) Revised:
2/10/00
8/9/01; 11/8/01; 5/15/03; 1/13/05; 11/18/10; 8/20/15
Purpose:
To provide guidelines regarding patient record release and retention
See policy statement introduction
POLICY: The Colorado Medical Board (“Board”) has adopted the following guidelines pertaining to the
retention and release of medical records.
I.
Medical Record Retention and Protection
A. Written Plan to Ensure Security of Patient Medical Records:
1.
Pursuant to 12-36- 140 of the Colorado Revised Statutes (“C.R.S.”), each
licensed physician and physician assistant (“licensee”) must develop a
written plan to ensure the security of patient records.
2.
A licensee shall attest at the time of license renewal that he or she has
developed a plan in compliance with section 12-36-140, C.R.S.
B. Notice to Patients Regarding Written Plan .
3.
A licensee shall provide written notice to each patient detailing the method
by which the patient may access or obtain his or her medical records in the
event the licensee dies, retires, or otherwise ceases to provide medical
care to patients.
C. Retention Period
1. The Board recommends retaining all patient records for a minimum of
seven years after the last date of treatment or seven years after the
patient reaches age 18- whichever occurs later.
2. In case of litigation or Board investigation, records must be retained until
resolution of the matter or seven years after last date of treatment or
seven years after the patient reaches age 18- whichever occurs later.
D. Disability, Death or Discontinuation of Practice
1. At the time of discontinuation of practice, patients should be notified and
instructed to submit a written authorization/release if they wish their
records transferred to another provider. Records should be retained after
discontinuation of practice using the guidelines above.
2. In the event of disability or death, it is the Board’s expectation that
associations, specialty societies, malpractice carriers, and Colorado
practitioners assist in the distribution of medical records in accordance
with the disabled/deceased providers’ written plan to ensure security of
patient records as defined in section I,A of this policy. Under no
circumstances will the Board take possession of the records or assume
responsibility for record security or distribution.
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II.
Medical Record Release
A. Absent exceptions as set forth in section 25-1-802 of the Colorado Revised Statutes,
(“C.R.S .“),patient medical records shall be available to the patient upon the patient’ s or
authorized patient representative’s submission of a valid authorization and upon reasonable
notice.
1. Form of Request : A valid authorization for release of records must:
 be made in writing;
 clearly identify the patient; and,
 be signed and dated by the patient or authorized patient
representative
2. Reasonable Notice: Except where medical urgency otherwise requires a
more prompt response, 30 days is reasonable notice for a medical records
request.
3. Medical Record.
a. Items such as x-rays, fetal monitor strips and electrocardiograms,
which may not at the time of the request be physically present in the
medical record, are nonetheless considered to be part of the record.
i.
If a patient’s medical record contains imaging the provider
should provide copies of all images as part of the response to a
request for patient medical records, unless the patient
specifically consents to not receive a copy of the image.
ii.
The provider may charge the requesting party the cost of
copying these records in advance.
b. Unless a summary of the case has already been prepared and is part of
the medical record (e.g. a hospital record at the time of discharge), a
provider is not obligated to provide one.
4. Fees
a. Providers may charge a reasonable fee for copying of records and may
request payment in advance.
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i.
The Board considers the rules promulgated by the Colorado
Department of Public Health and Environment (“CDPHE”)
setting forth reasonable costs for copies of medical records in
licensed facilities to be reasonable guidelines for physicians
providing copies of medical records.
ii.
It is customary when a patient is transferring care for the
provider to provide copies of records to another provider’s
office free of charge.
iii.
In those instances where a patient cannot, or chooses not to,
pay the fee for copying of medical records the provider must,
at a minimum, make the records available to the patient for
inspection or otherwise provide access to the records.
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40-8
Guidelines for Departure from a Medical Practice
Date Issued:
Date(s) Revised:
8/10/00
11//10/10; 8/20/15
Purpose:
To provide guidance regarding the departure from a medical practice.
POLICY: It is the position of the Colorado Medical Board (“Board”) that due care should be taken when
departing from a medical practice, to ensure a smooth transition from the current Colorado Medical Board
licensee (“provider”) to the new treating provider or other healthcare practitioner. This should occur
with a minimum of disruption in the continuity and quality of medical care being provided to the patient.
During such times, providers and other parties that may be involved in such processes must consider how
their actions affect patients. In particular practitioners have the following obligations:
Permit Patient Choice
It is the patient’s decision from whom to receive care. Therefore, it is the responsibility of all providers and
other parties that may be involved to ensure that:
 Patients are notified of changes in the practice. This is often best done by letter to patients who
are currently, or have recently been under the provider’s care, and should explain the changes
in the practice, and the final date of practice;
 In accordance with the requirements of Section 12-36-140, C.R.S, patients are advised as to
where their medical records will be stored, and how they may access those records;
 Patients are advised as to how to reach the provider(s) or other health care practitioner(s)
remaining in the practice; and,
 Patients clearly understand that the choice of health care provider is the patients’.
Providers continue to have obligations toward patients during and after departure from a medical practice.
Providers may not abandon a patient or abruptly withdraw from the care of a patient. Therefore, patients
should be given reasonable advance notice to allow their securing other care.
Good continuity of care includes preserving, keeping confidential, and providing appropriate access to
medical records. If patients choose to leave the practice and seek care elsewhere, allow considerable time
for patients to request that their records be copied and forwarded to the new treating provider or
healthcare practitioner. (See Board Policy regarding retention and release of medical records.) Also, good
continuity of care may often include making appropriate referrals. The provider(s) and other parties that
may be involved should ensure the requirements for continuity of care are effectively addressed.
Notifying Other Parties
In addition to notifying patients, there are other parties who will need to know of the change in
your practice. Contact:
 the Medical Board office to update your address of record;
 your malpractice insurance carrier to advise them of the change in your practice status;
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 any managed care organizations which have not already been advised; and,
 provider membership organizations (e.g. AMA, AOA,CAPA, specialty societies) may also want
to know of the change in your practice status.
No provider, group of providers , or other parties that may be involved should interfere with the fulfillment
of these obligations including, but not limited to, those obligations to permit patient choice. Providers
should not put themselves in a position where they cannot be assured these obligations will be met.
In the event that a provider leaves a practice, the practice or the departing provider should provide
adequate notice to all patients regarding the provider’s departure.
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40-9
Guidelines for Prescribing for Unknown Patients
Date Issued:
Date(s) Revised:
11/16/00
5/11/06; 7/1/10; 8/20/15
Purpose:
To provide guidance regarding prescribing of medications for patients
unknown to the provider
POLICY: It is the position of the Colorado Medical Board (“Board”) that it is unprofessional conduct for a
provider to provide treatment and consultation recommendations, including issuing a prescription, via any
means, unless a provider-patient relationship, as defined in Board Policy 40-3, has been established.
Prescribing for a patient whom the provider has not personally examined may or may not be suitable under
certain circumstances. Such circumstances may include, but are not limited to, admission orders for a
newly hospitalized patient, prescribing for a patient of another provider for whom the provider is taking
call, or continuing medication on a short-term basis for a new patient prior to the patient's first
appointment. Providers of medical care through telehealth technologies should adhere to the guidelines
articulated in Board Policy 40-27.
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40-10
Treating Partners of Patients with Sexually Transmitted Infections
Date Issued:
Date(s) Revised:
5/10/01
7/1/10; 8/20/15
Purpose:
To provide guidance regarding prescribing of medications for partners of
patients with sexually transmitted infections
POLICY: Acknowledging the concern and dilemma which occurs when a provider encounters a patient
with a sexually transmitted infection, and the partner of the patient does not come to the providers
office and has not been treated, The Colorado Medical Board (“Board”) adopts the following guidelines
regarding prescribing to unknown patient/partners of patients with sexually transmitted infections.
It is the position of the Board that the public risk of untreated sexually transmitted infection is greater
than the risk of complications from prescribing in this less than ideal setting. There is compelling need
for the partner of a patient with a sexually transmitted infection to receive treatment in the form of
prescription medications. While the ideal treatment situation is one in which each partner visits his or
her primary healthcare provider for treatment, such is not often the case.
Accordingly, treating
partners of patients with sexually transmitted infections is generally considered acceptable and
desirable if the partner will not seek treatment from his or her primary healthcare provider.
In these situations, the provider should counsel the patient that his or her partner must take the
medication as prescribed and should follow-up with his or her own healthcare provider. Further it should
be made clear to the patient that If the partner has any drug allergy or is on any medication, he or she
should consult with a healthcare provider before filling the prescription.
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40-11
Sales of Products in Medical Offices
Date Issued:
Date(s) Revised:
5/10/01
8/14/03; 7/1/10; 2/18/16
Purpose:
To provide guidance regarding the sale of products in medical offices
POLICY: It is the position of the Colorado Medical Board (“Board”) that the in-office sale of products,
including prescription drugs, to patients by physicians, physician assistants, or anesthesiologist assistants
(hereinafter “licensees”) potentially creates a financial conflict of interest. Any activity that creates a
conflict of interest casts doubt on the licensees’ ability to fulfill fiduciary obligations and undermines the
patient's trust. In-office sales transactions risk exploiting the inherent imbalance of power in the
provider-physician relationship. In many cases, patients lack the expertise and independent judgment to
make a proper determination about their need for the product and have no alternative reliable source of
information. They may feel compelled to buy an item because they wish to secure the doctor's favor, or
because they have placed implicit trust in their doctor's judgment and believe that he or she is acting in
their best interest. Because of the risk of patient exploitation, licensees should take steps to minimize
financial conflict of interest.
One mechanism to limit the conflict of interest is to take the element of financial gain out of the
transaction. Many licensees distribute health-related products to their patients free of charge. In other
cases, licensees sell health-related products to their patients at cost, in order to make useful products
readily available to their patients. An "at cost" sale refers to the sale of products at a price that covers
the reasonable expense of obtaining, storing, and dispensing the products.
Another mechanism to minimize conflict of interest is to limit the appropriateness of sales to
those circumstances that serve the immediate and pressing needs of patients.
One of the most important safeguards to limit conflicts of interest is disclosure. Licensees selling
health-related products should disclose to the patient their financial arrangements with the
manufacturer or the supplier of the product.
In-office sales of health-related products for which the licensee claims to offer a unique benefit to
patient health and are available only through licensees raises concern for the potential of a coercive
relationship or other boundary violation.
Licensees should not sell non-health-related goods from their offices or other treatment settings, with
one exception. Licensees may sell non-health-related goods from their offices for the benefit of
community organizations provided that: (a) the goods in question are low-cost; (b) the licensee takes no
share in profit from their sale; (c) such sales are not a regular part of the licensees’ business; (d) sales
are conducted in a dignified manner; and (e) sales are conducted in such a way as to assure that patients
are not pressured into making purchases.
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40-12
Office-Based Surgery and Anesthesia
Date Issued:
Date(s) Revised:
11/8/01
7/1/10, 5/19/16
Purpose:
To provide guidance regarding office-based surgery and anesthesia
Introduction
This policy provides guidance regarding the provision of surgical and anesthesia services in office
settings. The Board identifies the roles and responsibilities of physicians providing, or overseeing by
proper delegation, surgical and/or anesthesia services in office settings. This policy does not extend or
limit the scope of any license. Further, this policy is to be used in concert with evidence-based
guidelines and state and federal requirements governing the provision of office based surgery and
anesthesia.
This policy does not apply to minor surgical procedures performed under topical or local infiltration
blocks. This policy applies to any procedure involving general and/or regional anesthesia and/or the
use of conscious sedation.
For purposes of this policy "office based surgery" is defined as surgery that is performed outside of a
facility licensed by the Colorado Department of Public Health and Environment.
Guidelines for Office Based Surgery and Anesthesia
1. Selection of Procedures and Patients
It is the responsibility of the surgeon to determine that the office is an appropriate forum for
the particular procedure(s) to be performed on the particular patient. Furthermore, it is the
responsibility of the surgeon and, when involved, the qualified anesthesia provider to
determine that the patient is an appropriate candidate for the anesthesia to be provided in the
office setting.
However , it is the opinion of the Colorado Medical Board that under generally accepted
standards of practice in Colorado, the following procedures should not be performed in the
office:
a) Procedures that may result in blood loss of more than 4% of the estimated blood
volume in a patient with a normal hemoglobin;
b) Procedures requiring major or prolonged intracranial, intrathoracic, or abdominal
cavity entry;
c) Joint replacement procedures;
d) Procedures directly involving major blood vessels; and
e) Emergent or life threatening procedures.
f)
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1)
Should not result in the removal of more than 5% of total body weight in
supernatant fat or more than 4500 cc of supernatant fat, whichever is less;
2)
Should not involve the use of more than 55mg/kg of Lidocaine for pure
tumescent anesthesia;
3)
Should, where epinephrine is utilized, use a concentration of epinephrine in
tumescent solutions of 0.25 mg/L to 1.5 mg/L. The total dosage of epinephrine should
be minimized, within these limits, and usually should not exceed 50 mcg/kg;
4)
Should not result in the removal of more than 1500 cc of supernatant fat when
combined with any other extensive surgical procedure; and
5)
Should include appropriate monitoring of the patient as defined in paragraph
5(a)(2) of this policy statement.
The recommendations for limits on local anesthetic and supernatant fat are limits that may be
safely observed by skilled physicians well trained in these techniques. Physicians without
extensive training or experience in this area should not attempt to approach these limits.
2. Preoperative Evaluation
An appropriate preoperative evaluation, including history and physical, must be conducted
prior to the performance of any surgery, regardless of setting. The surgeon must evaluate and
discuss the risks and benefits of the surgical procedure with the patient and obtain informed
consent from the patient. Additionally, the surgeon and qualified anesthesia provider must
assess the patient before surgery to evaluate the risk of anesthesia.
3. Transfer Agreement
A written transfer agreement with a licensed hospital within reasonable proximity should be
obtained for emergency purposes. For the purposes of these guidelines, "reasonable proximity"
is defined as less than thirty minutes transport time from office to hospital.
4. Records
The surgeon must maintain complete records of each surgical procedure; this would include
anesthesia records when applicable. The records must contain documentation of informed
consent from the patient. The record should document that the patient is medically stable
before discharge. A discharge order should be written.
5. Anesthesia
a) Definitions:
1)
For purposes of these guidelines, a "qualified anesthesia provider" is an
appropriately trained and qualified physician, a certified registered nurse anesthetist
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("CRNA"), or a physician assistant ("PA") appropriately trained and qualified in
anesthesia working under the on-site supervision of a physician.
2)
For the purposes of these guidelines, "monitoring a patient" includes ongoing
evaluation of the patient's oxygenation, ventilation, circulation and temperature.
b) Administration of any general or regional anesthetic should be done by a qualified
anesthesia provider. Administration of conscious sedation, when not done by a qualified
anesthesia provider, should be directly supervised by a qualified physician.
c) A qualified anesthesia provider must be continuously present to monitor the patient
when general or regional anesthesia is being used.
d) During any surgery where general or regional anesthesia or conscious sedation is given,
qualified personnel in addition to the operating surgeon should be continuously present to
monitor the patient.
e) All facilities should have a reliable source of electricity, oxygen, suction, resuscitative
equipment and emergency drugs.
f) If services are being provided to infants or children, appropriately sized equipment,
medication and resuscitative capabilities must be available.
g) When inhalation anesthesia is used, an anesthesia machine that is monitored and
maintained in accordance with the standards of the American Society of Anesthesiologists
should be used.
h) Explosive anesthetics should not be used.
i) Personnel with training in appropriate resuscitative techniques (ACLS or PALS) should
be immediately available until all patients who have received anesthesia are discharged.
j)
The patient should not be discharged home until the patient is medically stable.
k) At least 36 ampules of dantrolene must be immediately available for any procedures
when general anesthesia and/or succinylcholine are administered.
6. Duration of Surgery
The planned duration of the surgical procedure(s) for each patient should be reasonable with
respect to both the capabilities and training of the personnel available to monitor the patient
and the nature of the facility.
It is not recommended that a patient stay overnight in an office setting following a surgical
procedure unless that facility is appropriately accredited. "Accredited ambulatory surgical
centers" are accredited as a Class B or Class C facility by one of the following organizations:
Joint Commission on Accreditation of Healthcare Organizations (JCAHO); American Association
for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF); Accreditation Association for
Ambulatory Health Care, Inc. (AAHC); or the Colorado Department of Public Health and
Environment.
7. Complications and Emergencies
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a) If a patient does not meet discharge criteria and is not in a Class B or Class C facility,
the patient should be transferred to an appropriately accredited ambulatory care center or
a licensed hospital within reasonable proximity.
b) The facility should have written protocols for cardiopulmonary emergencies.
c) The surgeon and at least one assistant should be currently certified in Basic Life
Support. Additionally, if a qualified anesthesia provider is not managing the anesthesia,
the surgeon and at least one assistant should be currently certified in Advanced Cardiac
Life Support.
d) All facility personnel should be appropriately trained in and regularly review the
facility's written emergency protocols.
e) The facility should have written protocols for external events that may affect officebased surgical procedures, such as fire, flood or tornadoes.
f) Back-up power sufficient to ensure patient protection in the event of an emergency
should be available.
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40-13
Use of Alcohol, Marijuana and Other Mind- Altering Substances While
Engaging In Patient Care Responsibilities Including On-call Services
Date Issued:
Date(s) Revised:
11/14/02
8/14/03; 07/01/10; 2/18/16
Purpose:
To clarify the Board’s position regarding the use of alcohol, marijuana or other
mind-altering substances while on-call
POLICY: The Colorado Medical Board (“Board”) strongly cautions against a physician’s, physician
assistant’s or anesthesiologist assistant’s ( hereinafter “licensee”) use of mind-altering medication, not
prescribed by licensee’s treating provider, while engaging in patient care responsibilities including the
provision of on-call services.
The Board, at its discretion, may determine if a licensee's use of alcohol, marijuana or other mindaltering substance had the potential to jeopardize patient safety. In such an instance, the Board may
conclude that a violation of the Medical Practice Act occurred, and it retains the right to initiate
disciplinary action against the licensee's ability to practice.
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40-17
Guidelines Regarding Practice Coverage Outside of Normal Office
Hours
Date Issued:
Date(s) Revised:
5/13/04
7/1/10; 2/18/16
Purpose:
To clarify the Board's expectations with respect to practice coverage and the
communication of coverage arrangements to patients.
POLICY: The Colorado Medical Board ("Board") has adopted this policy to provide guidance to physicians,
physician assistants and anesthesiologist assistants (hereinafter “licensees”) regarding its expectations
with respect to practice coverage and the communication of the coverage arrangements to patients with
whom a provider/patient relationship has been established.
This policy is not meant to address those unanticipated situations that require the patient to
immediately seek emergency services.
Applicability:
This policy applies to licensees who provide care to patients on an ongoing basis. This policy also applies
to licensees who provide discrete medical services that have an identifiable beginning and end. For
licensees providing such discrete services, this policy applies until such time as follow-up care is no
longer expected and is no longer required under generally accepted standards of medical practice.
This policy is in addition to any coverage requirements of an institution or facility.
Guidelines:
1. It is the duty of the licensee to provide care whenever it is needed or to assure that proper
coverage is available to care for the patient at all times. Consequently, it is expected that the
licensee will have an explicit coverage arrangement to assure continued care for patients
outside of normal office hours or when otherwise unavailable.
2. Ideally, the licensee will have well codified coverage arrangements with providers within the
same practice or specialty or within an institution or facility.
3. In the event that the arrangements described in paragraph 2 cannot be made, the licensee may
choose to enter into an agreement with an established triage center, facility or institution
qualified to handle the needs of the licensees’ patients. The agreement should be explicit,
preferably in writing. However, when using this coverage arrangement, there must still be a
mechanism for the triage center, facility or institution staff to know whom to call for questions
or dispositions regarding those patients who are seen in the triage center, facility or institution
or counseled on the telephone.
4. At a minimum, an emergency department ("ED") may provide after-hours coverage for urgent
care so long as the ED understands and agrees in advance to provide this service for the licensee
and the licensees’ patients. The agreement should be explicit, preferably in writing. However,
when using this coverage arrangement, there must still be a mechanism for the ED to know
whom to call for questions or dispositions regarding those patients who are seen in the ED or
counseled on the phone. This would include, but may not be limited to, designating which
providers should attend to any potential admissions and assuring a mechanism exists to receive
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information regarding the patient's ED course and scheduled follow-up, as deemed appropriate
by the ED.
5.
Generic communications to patients, by answering machine for example, simply to go to an
ED for after-hours care do not replace a licensees’ obligation to provide coverage as stated
above.
6.
Licensees’ should create a written plan for coverage or transition of care to an appropriate
provider in the event of a future incapacitation or other unplanned absence from practice.
7.
It is the licensees’ responsibility to assure that the practice coverage policy is communicated
to patients in a clear and understandable way. It is preferable that the policy be
communicated to patients verbally and in writing (i.e. a patient brochure) at the time the
provider/patient relationship is initially established. Subsequent changes to the practice
coverage policy also need to be communicated to patients. The Board also suggests that
licensees consider posting their coverage policy in the office reception area as a reminder to
patients.
8.
Failure of a licensee to adhere to these guidelines may be considered patient abandonment by
the Board, which may constitute unprofessional conduct pursuant to Section 12-36-117, CRS.
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40-18
Self-Treatment and Treatment of Family Members or Others with Whom
Significant Emotional Relationship Exists
Date Issued:
Date(s) Revised:
10/13/05
7/1/10; 2/18/16
Purpose:
To clarify the Board’s position regarding licensees’ self-treatment and
treatment of family members or others with whom significant emotional
relationship exists
POLICY: Section 12-36-117(1)(x) of the Colorado Revised Statutes provides that it is unprofessional
conduct and grounds for disciplinary action by the Board if a physician, physician assistant, or
anesthesiologist assistant (hereinafter “licensees”) prescribes, distributes or gives to a family member or
to oneself, except on an emergency basis, any controlled substance as defined in Section 18-18-204, CRS,
or as contained in Schedule II of 21 U.S.C., Section 812, as amended. Both of these statutory citations
refer to Schedule II controlled substances. Although not specifically prohibited by law, the Colorado
Medical Board (“Board”) also discourages licensees from prescribing or dispensing other controlled
substances to family members or others with whom significant emotional relationships exist for the
reasons set forth below.
In addition, it is the position of the Board that, except for minor illnesses and emergencies, licensees
should not treat, medically or surgically, or prescribe for themselves, their family members or others
with whom they have significant emotional relationships. The Board strongly believes that such
treatment and prescribing practices are inappropriate and may result in less than optimal care being
provided. A variety of factors, including personal feelings and attitudes that inevitably color judgment,
may compromise the objectivity of the licensee and make the delivery of sound medical care
problematic in such situations. True patient autonomy and informed consent may also be sacrificed.
When an emergency or a minor illness requires self-treatment or treatment of a family member or
other person with whom the licensee has a significant emotional relationship, the Board recommends
that the licensee prepare and keep a proper written record of that treatment including, but not limited
to, prescriptions written and the medical indications for those prescriptions.
Except as set forth above, the Board expects licensees to delegate the medical and surgical care of
themselves, their families and those with whom they have significant emotional relationships to
other healthcare professionals in order to ensure appropriate and objective care is provided and to
avoid misunderstandings related to their prescribing practices.
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40-19
User of Lasers to Provide Medical Services
Date Issued:
Date(s) Revised:
10/13/05
7/1/10; 2/18/16
Purpose:
To provide guidance regarding the use of lasers to provide medical services
POLICY: It is the position of the Colorado Medical Board (“Board”) that the revision, destruction,
incision, or other structural alteration of human tissue using laser technology constitutes the practice of
medicine as defined in Section 12-36-106 of the Colorado Revised Statutes. Laser surgery may only be
performed by a physician, another licensed healthcare provider working within his or her scope of
practice as defined in Colorado law, or by a person functioning as a delegatee of a licensed physician
and in accordance with the requirements of the Board. Those requirements are set forth in Board Rule
800 regarding the delegation and supervision of medical services to unlicensed healthcare providers
pursuant to Section 12-36-106(3)(l), CRS.
Licensees should only use devices approved by the Food and Drug Administration (FDA) unless
functioning under protocols approved by institutional review boards. It is the licensee's responsibility to
obtain adequate training for use of such devices and to make documentation of this training available to
the Board upon request.
Lasers are also employed in certain hair removal procedures, as are various devices that manipulate
and/or pulse light causing it to penetrate human tissue. It is the position of the Board that the use of
lasers or pulse light devices identified by the FDA as a Class II devices constitutes the practice of
medicine as defined in Section 12-36-106 of the Colorado Revised Statutes and may only be performed by
a physician, another licensed healthcare provider working within his or her scope of practice as defined
in Colorado law, or by a person functioning as a delegate of a licensed physician and in accordance with
the requirements of the Board. Those requirements are set forth in Board Rule 800 regarding the
delegation and supervision of medical services to unlicensed healthcare providers pursuant to Section 1236-106 (3)(l), CRS.
The use of devices, commonly known as electrolysis devices and identified by the FDA as Class I devices,
does not constitute the practice of medicine and, therefore, does not require physician oversight or
supervision.
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40-24
Clarifying The Scope of Practice of Physician Assistants
Date Issued:
Date(s) Revised:
2/18/10
7/1/10; 2/18/16
Purpose:
To clarify the scope of practice of Physician Assistants
POLICY: Pursuant to section 12-36-107.4, of the Colorado Revised Statutes (“C.R.S.”), a Physician
Assistant (“PA”) may provide medical services as authorized by the PA’s supervising physician and
consistent with Colorado Medical Board (“Board”) Rule 400. PAs may legally sign other documents and
forms typically requiring a physician signature as authorized by the PA’s supervising physician, and
consistent with Board Rule 400.
Examples include, but are not limited to, performing physical examinations required by an educational
institution and the completion of any required form regarding such examination; issuing discharge orders
for a patient including ordering needed supplies and equipment for the patient to use in the home or
rehabilitative setting; and verifying a disability for persons seeking parking privileges pursuant to
Section 42-3-204, C.R.S.
Please note that the above examples are illustrative only and not intended to be an exhaustive list.
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40-25
Sexual Misconduct Statement and Policy
Date Issued:
Date(s) Revised:
11/8/93
11/13/03; 07/1/10; 5/19/16
Purpose:
To clarify the Board’s position regarding sexual contact with current and
former patients and provide guidance to licensees
INTRODUCTION: The Medical Practice Act defines unprofessional conduct to include sexual
contact with a patient during the course of patient care or within six months immediately following
the termination of a physician, physician assistant, or anesthesiologist assistant’s (hereinafter
“licensees”) professional relationship with the patient. Section 12-36-117(1)(r), C.R.S. Some
provider-patient relationships, including those involving licensees providing mental health care
and treatment to patients, are never appropriate. Sexual contact with a patient by a licensee is
a violation of the Medical Practice Act and subjects the licensees’ license to disciplinary action by
the Board.
POLICY:
I.
SEXUAL MISCONDUCT. Sexual contact with a patient is sexual misconduct and is a violation
of Section 12-36-117(1)(r), C.R.S.
A.
II.
Sexual Misconduct does not include verbal or physical behavior that is required for
medically recognized diagnostic or treatment purposes when such behavior is
accomplished in a manner that meets the standard of care appropriate to the
diagnostic or treatment situation.
DEFINITIONS. Section 12-36-117(1)(r), C.R.S., defines unprofessional conduct as "engaging in
a sexual act with a patient during the course of patient care or within six months
immediately following the termination of the licensee's professional relationship with the
patient."
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A.
Sexual Act: A sexual act is defined as "sexual contact, sexual intrusion, or sexual
penetration as defined in Section 18-3-401, C.R.S."
B.
Sexual Contact: “the knowingly touching of the victim's intimate parts by the actor, or
of the actor's intimate parts by the victim, or the knowingly touching of the clothing
covering the immediate area of the victim's or actor's intimate parts if that sexual
contact can reasonably be construed as being for the purposes of sexual arousal,
gratification, or abuse.” Section 18-3-401(4), C.R.S.
C.
Sexual penetration: "sexual intercourse, cunnilingus, fellatio, analingus, or anal
intercourse. Emission need not be proved as an element of any sexual penetration. Any
penetration, however slight, is sufficient…". Section 18-3-401(6). C.R.S.
D.
Intimate Parts: “the external genitalia or the perineum or the anus or the pubes or the
breasts of any person.” Section 18-3-401(2), C.R.S.
E.
“During the Course of Patient Care”: Includes all sexual acts between the licensees
and patient during the period of time a provider-patient relationship exists and not just
during times of actual examination or treatment.
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III.
PROVIDER-PATIENT RELATIONSHIP
A. The determination of when a person is a patient for purposes of Section 12-36117(1)(r), is made on a case by case basis with consideration given to both the
definition of a provider-patient relationship set forth in Board Policy 40-3 and the
nature, extent and context of the professional relationship between the licensee
and the person. The fact that a person is not actively receiving treatment or
professional services from a licensee is not determinative of this issue. A person is
presumed to remain a patient until the provider-patient relationship is terminated.
B. Once a provider-patient relationship has been established, the licensee has the
responsibility to establish that the relationship no longer exists. The mere passage
of time since the patient's last visit to the licensee is not solely determinative of
the issue. Some of the factors considered by the Board in determining whether the
provider-patient relationship has terminated for purposes of Section 12- 36117(1)(r), C.R.S., include, but are not limited to, the following: formal termination
procedures; transfer of the patient's care to another provider; the reasons for
wanting to terminate the professional relationship; the length of time that has
passed since the patient's last visit to the provider; the length of the professional
relationship; the extent to which the patient has confided personal or private
information to the licensee; the nature of the patient's medical problem; the
degree of emotional dependence that the patient has on a licensee; the extent of
the licensees’ general knowledge about the patient.
1. Some provider-patient relationships may never terminate because of
the nature and extent of the relationship. These relationships may
always raise concerns of sexual misconduct whenever there is sexual
contact.
2. Sexual contact between a licensee and a former patient more than
six months after termination of the provider-patient relationship may
still constitute unprofessional conduct under other sections of the
Medical Practice Act if the sexual contact is a result of the
exploitation of trust, knowledge, influence or emotions derived from
the professional relationship. A relationship between a patient and a
psychiatrist or psychiatric PA constitutes such a relationship.
IV.
CONSENT: A patient's consent to, initiation of or participation in sexual behavior or
involvement with a licensee does not change the nature of the conduct nor lift the statutory
prohibition.
V.
IMPAIRMENT OR MENTAL CONDITION. In some situations, a licensee’s sexual contact with a
patient may be the result of impairment or a mental condition which may render the
licensee unable to practice medicine with reasonable skill and safety to patients pursuant
to Section 12-36-117(1)(o), C.R.S. Any such condition is also defined as unprofessional
conduct.
VI.
OTHER STATUTORY PROHIBITIONS. Sexual contact with patients may also constitute the
basis for other forms of unprofessional conduct under the Medical Practice Act. For
example, engaging in sexual contact with a patient may also fall below generally accepted
standards of professional practice and so constitute a violation of Section 12-36-117(1)(p),
C.R.S. Furthermore, to the extent that the sexual contact results in a conviction of a
felony, it is also unprofessional conduct under Section 12-36-117(1)(f), C.R.S.
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VII.
DISCIPLINE. Upon a finding that a licensee has committed unprofessional conduct by engaging
in sexual misconduct, the Board will impose such discipline as the Board deems necessary to
protect the public. The sanctions available to the Board are set forth in Section 12-36118(5)(g)(III), C.R.S., and include restriction or limitation of the licensees’ practice,
suspension, or revocation of the licensees’ license.
VIII.
GUIDANCE: It is the licensees’ responsibility to maintain the boundaries of the professional
relationship by avoiding and refraining from sexual contact with patients. To this end, the
Board strongly recommends the following:
A. Licensees must respect a patient's dignity at all times and should provide appropriate
gowns and private facilities for dressing, undressing and examination. In most situations,
a licensee should not be present in the room when a patient is dressing or undressing.
B. A licensee should consider having a chaperone present during examination of any
sensitive parts of the body for protection of both the patient and the licensee. A licensee
should refuse to examine sensitive parts of a patient's body without a chaperone present
if the licensee believes the patient is sexualizing the examination.
C. To minimize misunderstandings and misperceptions between a licensee and patient, the
licensee should explain the need for each of the various components of an examination
and for all procedures and tests.
D. Licensees should choose their words carefully so that their communications with a
patient are clear, appropriate and professional.
E. Licensees should be alert to feelings of sexual attraction to a patient and may wish to
discuss such feelings with a colleague. To maintain the boundaries of the professional
relationship, a licensee should transfer the care of a patient to whom the licensee is
attracted to another provider and should seek help in understanding and resolving
feelings of sexual attraction without acting on them.
F. Licensees must be alert to signs indicating that a patient may be encouraging a sexual
relationship and must take all steps necessary to maintain the boundaries of the
professional relationship including transferring the patient.
G. Licensees should not discuss their intimate personal problems/lives with patients.
H. Licensees should seek out information and formal education in the area of sexual
attraction to patients and sexual misconduct, and should in turn educate other health
care providers and students.
Finally, the Board reminds all licensees of their statutory duty to report to the Board any licensee
known or believed to have engaged in sexual misconduct, or any act which may constitute
unprofessional conduct or which may indicate that a licensee is unable to practice medicine with
reasonable skill or safety to patients.
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40-26
Quad Regulator Policy for Prescribing and Dispensing Opioids
Date Issued:
Date(s) Revised:
07/25/14
Purpose:
To provide guidance regarding the prescribing and dispensing of opioids
Policy for Prescribing and Dispensing Opioids
Colorado Dental Board, Colorado Medical Board, State Board of Nursing, and State
Board of Pharmacy
In collaboration with the Nurse-Physician Advisory Task Force for Colorado
Healthcare
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PREAMBLE
Prescribing and dispensing medication for the appropriate treatment of pain is a
priority for Colorado healthcare providers. However, in 2013 the misuse and abuse of
prescription opioids became a public health epidemic in the United States in general,
and Colorado in particular, leading to drug addiction, death from overdose, and
increased costs to society.
In order to address this crisis, the Colorado Dental Board, Colorado Medical Board,
State Board of Nursing, State Board of Pharmacy, and the Nurse-Physician Advisory Task
Force for Colorado Healthcare collaborated to identify opportunities and provide
meaningful guidance to prescribers and dispensers in Colorado.
The Boards recognize that reversing the trend of opioid misuse and abuse requires
coordinated efforts to increase public awareness, take-back events for safe disposal,
addiction treatment and recovery options, and enforcement, among others. The
Boards and the practitioners they license are one part of a multi-pronged solution.
The Boards recognize the complexities faced by prescribers in the appropriate
management of pain.1 The demands on practitioners considering opioid prescribing
differ depending on patient diagnosis, practice settings, and/or conditions.
Importantly, long-term therapies addressing cancer-related treatment, palliative
and/or hospice care involve different considerations from short-term therapies
appropriate for acute or chronic non-cancer pain.
Pain and addiction specialists play an important role in healthcare and the communities
they serve to compassionately and safely care for patients. Many of the tools and
practices referenced in this policy were developed by such specialists. The need for
therapeutic care of pain in Colorado patients exceeds the supply of specialists in the
state. However, other types of providers can successfully treat many painful
conditions and achieve the function and relief the patient seeks. Accordingly, this
policy is intended to educate prescribers and dispensers broadly by providing useful
tools that may be utilized at the point-of-care to support clinical decision making.
The Boards further recognize that decreasing opioid misuse and abuse in Colorado
should be addressed by collaborative and constructive policies aimed at improving
prescriber education and practice, decreasing diversion, and establishing the same
guidelines for all opioid prescribers and dispensers. This includes opioid therapies for
both acute and chronic non-cancer pain, 2 because the Boards find that treatment for
pain often does not fall clearly into one category or another.
Diversion and “doctor shopping” accounts for 40% of drug overdose deaths. 3 To address
the dual issues of access to appropriate pain management and opioid-related adverse
outcomes, prescribers have dual obligations: to manage pain and improve function
while reducing problems resulting from misuse and abuse of prescription opioids in the
1
“Boards” as used in this policy means the Boards overseeing prescribing and dispensing of opioids and involved in
the drafting of this policy: the Colorado Medical Board, State Board of Nursing, Colorado Dental Board, and the
State Board of Pharmacy.
2
Pain is categorized by a number of descriptors ranging from duration, impact, or physiological response, among
others. For the purpose of this policy, the term "chronic, non-cancer pain" is utilized to refer to pain that lasts
longer than 90 days and is non-terminal. It does not include conditions such as cancer, scleroderma, multiple
sclerosis, muscular dystrophy, or rheumatoid arthritis.
3
Paulozzi, L., Baldwin, G., Franklin, G., Ghiya, N., & Popovic, T. (2012). CDC Grand Rounds: Prescription drug
overdoses — a U.S. epidemic. Center for Disease Control and Prevention, Morbidity and Mortality Weekly Report
(MMWR), 61(01), 10-13. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm
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patient and community. Pharmacists share a corresponding responsibility with the
prescriber to assure that a prescription order is valid in all respects and is appropriate
for the patient and condition being treated.
Therefore, the Boards have agreed to the following guidelines regarding opioid
prescriptions in Colorado. Providers prescribing and/or dispensing opioids should:
● Follow the same guidelines
● Use the Colorado Prescription Drug Monitoring Program (PDMP)
● Be informed about evidence-based practices for opioid use in healthcare and
risk mitigation
● Educate patients on appropriate use, storage and disposal of opioids, risks and
the potential for diversion
● Collaborate within the integrated healthcare team to decrease overprescribing, misuse and abuse of opioids.
Opioid prescribers and dispensers must conform to the regulations set forth by the
respective licensing board and other laws.
To this end, we, the Boards regulating the prescribers and dispensers in Colorado, have
developed this joint policy incorporating the guidelines above.
This policy provides guidelines, and does not set a standard of care for prescribers and
dispensers. This policy represents the Boards’ current thinking on this topic. It does
not create or confer any rights for or on any person and does not operate to bind
Boards or the public. Prescribers may use an alternative approach if the approach
satisfies the requirements of the applicable statutes, regulations, and standard of care.
The Boards will refer to current clinical practice guidelines and expert review in
approaching cases involving the management of pain. 4
4
A “policy” is adopted by a board to provide guidance to licensees regarding the board’s position on various
subjects. Policies are unlike statutes or rules in that they are not law. Conversely, “board rules” have the force of
law and set forth requirements to which licensees must adhere.
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Table of Contents
BEFORE PRESCRIBING OR DISPENSING .......................................................................................... 1
WHEN PRESCRIBING OR DISPENSING ........................................................................................... 2
PRESCRIBING AND DISPENSING FOR ADVANCED DOSAGE, FORMULATION OR DURATION ......................................... 3
PATIENT EDUCATION .......................................................................................................... 4
DISCONTINUING OPIOID THERAPY .............................................................................................. 4
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BEFORE PRESCRIBING OR DISPENSING
Develop and maintain competence
Prescribers, including prescribers who dispense, must maintain competence to assess
and treat pain to improve function. This includes understanding current, evidencedbased practices and using other resources and tools related to opioid prescribing and
dispensing. In some clinical situations consultation with a specialist is appropriate.
Pharmacists must maintain competence in the appropriateness of therapy. See the
Appendix for a list of resources and tools for developing and maintaining competence.
Utilize safeguards for the initiation of pain management
The decision to prescribe or dispense opioid medication for outpatient use may be
made only after a proper diagnosis and complete evaluation which should include a risk
assessment, pain assessment, and review of relevant PDMP data. These safeguards
apply to acute and chronic, non-cancer pain but not to palliative end-of-life care.
Not all pain requires opioid treatment. Prescribers should not prescribe opioids when
non-opioid medication is both effective and appropriate for the level of pain.
1. Diagnose
Prescribers should establish a diagnosis and legitimate medical purpose appropriate for
opioid therapy through a history, physical exam, and/or laboratory, imaging or other
studies. A bona fide provider-patient relationship must exist.
2. Assess Risk
Prescribers should conduct a risk assessment prior to prescribing opioids for outpatient
use and again before increasing dosage or duration. Risk assessment is defined as
identification of factors that may lead to adverse outcomes and may include:
● Patient and family history of substance use (drugs including alcohol and
marijuana)
● Patient medication history (among other reasons, this is taken to avoid unsafe
combinations of opioids with sedative-hypnotics, benzodiazepines,
barbiturates, muscle relaxants or to determine other drug-drug interactions)
● Mental health/psychological conditions and history
● Abuse history including physical, emotional or sexual
● Health conditions that could aggravate adverse reactions (including COPD, CHF,
sleep apnea, elderly, or history of renal or hepatic dysfunction)
● Prescribers and dispensers should observe the patient for any aberrant drugrelated behavior and follow-up appropriately when aberrant drug-related
behavior is presented. See the Appendix for a description of such behaviors.
See the Appendix for additional resources related to assessment, including resources
for alcohol and substance use screening and guidelines for treating patients with risk
factors.
If the assessment identifies risk factors, prescribers should exercise greater caution
before prescribing opioids as detailed in subsequent sections, consider conducting a
drug test or consulting a specialist and put in place additional safeguards as part of the
treatment plan.
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3. Assess Pain
An appropriate pain assessment should include an evaluation of the patient’s pain for
the:
● Nature and intensity
● Type
● Pattern/frequency
● Duration
● Past and current treatments
● Underlying or co-morbid disorders or conditions
● Impact on physical and psychological functioning
4. Review PDMP
Prescribers and dispensers should utilize the Prescription Drug Monitoring Program
(PDMP) prior to prescribing or dispensing opioids.
Collaborate with the healthcare team
Prescribers and dispensers should collaborate within the healthcare team to prevent
under-prescribing, over-prescribing, misuse and abuse of opioids. See the Appendix for
additional resources.
WHEN PRESCRIBING OR DISPENSING
Verify a provider-patient relationship
A bona fide provider-patient relationship must exist. The prescriber or dispenser
should verify the patient’s identification prior to prescribing or dispensing opioids to a
new or unknown patient.
For pharmacists, this includes exercising judgment and conducting research if
appropriate (such as use of the PDMP or communication with the prescriber or relevant
pharmacies) when the prescription order is:
● For a new or unknown patient
● For a weekend or late day prescription
● Issued far from the location of the pharmacy or patient’s residential
address
● Denied by another pharmacist.
Additional Safeguards
Ensure the dose, quantity, and refills for prescription opioids are appropriate to
improve the function and condition of the patient, at the lowest effective dose and
quantity, in order to avoid over-prescribing opioids.
Factors that have been associated with adverse outcomes include: 1) opioid doses
greater than 120 mg morphine equivalents per day 2) certain formulations and 3)
treatment exceeding 90 days. Additional safeguards have been found to reduce these
risks.
Dosage
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Opioid doses >120 mg morphine equivalents per day is a dosage that the Boards
agree is more likely dangerous for the average adult (chances for unintended death are
higher) over which prescribers should use clinical judgment, put in place additional
safeguards for the treatment plan (such as utilizing a treatment agreement), consult a
specialist or refer the patient; and dispensers should be more cautious. 5
Benzodiazepines are known to potentiate the effects of opioids and may increase the
risk of adverse outcomes. See the Appendix for additional resources on dose
calculators
Formulation
In addition to noting and responding to this dosage marker, prescribers and dispensers
must use clinical judgment regardless of dose, especially when:
 The prescription is considered an outlier to what is normally prescribed, or
 Transdermal, extended relief or long-acting preparation is prescribed.
Duration
Treatment exceeding 90 days should be re-evaluated as opioids may no longer be as
effective.
One way to distinguish pain is as either acute (that lasting less than 90 days) or chronic
(that lasting 90 days or greater). Management of each presents its own unique
challenges. The overwhelming majority of prescribers treat patients with acute pain; in
fact the pain for these patients lasts considerably less than 90 days.
If a prescriber extends short-term treatment, and results in exceeding 90 days,
prescribers should re-conduct the risk and pain assessments, review the PDMP and
undertake the additional safeguards.
PRESCRIBING AND DISPENSING FOR ADVANCED DOSAGE, FORMULATION OR DURATION
Tools and Trials
Prior to issuing prescriptions that are outliers to the dosage, formulation and duration
guidelines described above (for chronic, non-cancer pain), prescribers should
determine whether the patient improves functionally on opioids, which could include
an opioid trial, and whether the pain relief improves his/her ability to comply with the
overall pain management program.
Monitoring
The prescribing and dispensing of opioids for chronic pain must be monitored on an
ongoing basis, such as:
 assessing for improved function
 rechecking the PDMP, and
 random drug screening according to the prescriber’s clinical assessment.
5
Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M.
Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152(2):85-92.
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These monitoring tools and others should be documented in a treatment agreement
signed by the patient, described more below. Prescribers should not increase an initial
opioid dosage without rechecking the PDMP.
Treatment Agreements
Prescribers should utilize treatment agreements (also commonly referred to as a plan
or contract) and should ensure the patient understands the terms of the agreement.
This may be accomplished by having the patient review and sign the treatment
agreement.
A treatment agreement often includes information about proper:
● Goals of treatment
● Patient education (proper use, risks of addiction, alternatives)
● Controls (single prescriber, single pharmacy for refills)
● Random drug testing and restrictions on alcohol use
● Storage, disposal, and diversion precautions (including detailed precautions
related to adolescents and/or children and visitors to the home).
● Process and reasons for changing/discontinuing the treatment plan;
communicating reduction or increase of symptoms; and referring to a
specialist.
See the Appendix for resources on sample agreements.
PATIENT EDUCATION
Prescribers should educate patients regardless of the dosage, formulation and duration
of opioid therapy on proper use, risks of addiction, alternatives, storage, and disposal
of opioids and the potential for diversion (see the Appendix for resources on disposal).
Risks may include but are not limited to: overdose, misuse, diversion, addiction,
physical dependence and tolerance, interactions with other medications or substances,
and death.
Pharmacists should offer to review information with the patient about risks, disposal,
and other applicable topics.
Providers should educate patients about the risks and benefits of medications that
exceed the dosage, formulation and duration guidelines indicated above which may
place them at increased risk for long-term dependence and unintended adverse drug
effects. Patients who have a previous history of substance use disorder (including
alcohol) are at elevated risk.
When alerted to these risk factors, patients can make more informed decisions about
their healthcare treatment. For example, some patients have reduced or forgone
opioids when alerted to the risk factors. If a decision is made to continue with opioid
therapy, a satisfactory response to treatment would be indicated by a reduced level of
pain, increased level of function and/or improved quality of life. The use of an
interdisciplinary team and family members may be considered as a part of the
treatment plan and ongoing monitoring.
DISCONTINUING OPIOID THERAPY
The prescriber should consider discontinuing opioid therapy when:
● The underlying painful condition is resolved;
● Intolerable side effects emerge;
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The analgesic effect is inadequate;
The patient’s quality of life fails to improve;
Functioning deteriorates; or
There is aberrant medication use.
The prescriber discontinuing opioid therapy should employ a safe, structured tapering
regimen through the prescriber or an addiction or pain specialist. There is a risk of
patients turning to street drugs or alcohol abuse if tapering is not done with
appropriate supports. Prescribers of opioids should be familiar with treatment options
for opioid addiction. See the Appendix for tips on tapering.
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APPENDIX
PDMP
Colorado Prescription Drug Monitoring Program (PDMP):
http://www.hidinc.com/copdmp
Preventing diversion through appropriate disposal
In order to prevent diversion, providers should provide information regarding
appropriate disposal, including the following:
● Secure unused prescription opioids until such time they can be safely
disposed. Specifically, ensure that prescription opioids are not readily
accessible to other family members (including adolescents and/or children) or
visitors to the home.
● Take-back events are preferable to flushing prescriptions down the
toilet or throwing them in the trash. Only some medications may be flushed
down the toilet. See the FDA’s guidelines for a list of medications that may be
flushed: www.fda.gov
● Utilize take-back events and permanent drop box locations
● Utilize DEA disposal guidelines if take-back or drop boxes are
unavailable. Those guidelines include:
● Take the drugs out of their original containers and mix them
with an undesirable substance, such as used coffee grounds or kitty
litter; then put them in a sealable bag, empty can, or other
container to prevent the medication from leaking out of a garbage
bag;
● Before throwing out a medicine container, tell the patient to
scratch out all identifying information on the prescription label to
protect their identity and personal health information; and
● Educate patients that prescriptions are patient specific.
Patients may not share prescription opioids with friends, family or
others and may pose serious health risks, including death.
● Use activated charcoal absorption technologies to inactivate unused
medications or used fentanyl patches.
Record keeping
Prescribers who treat patients with opioids should maintain accurate and complete
medical records according to the requirements set forth by their licensing board.
Discontinuing/tapering opioid therapy
Weaning from opioids can be done safely by slowly tapering the opioid dose and taking
into account several factors related to risk, symptom, and alternatives.
Opioid Taper Plan and Calculator:
“Interagency Guidelines on Opioid Dosing for Chronic Non-Cancer Pain” State of
Washington Agency Medical Directors Group. 2010 Online:
www.agencymeddirectors.wa.gov
Withdrawal Symptoms Assessment:
“Clinical Opiate Withdrawal Scale” The National Alliance for Advocates for
Buprenorphine Treatment. Online at: www.naabt.org
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Aberrant drug-related behavior
Prescribers and dispensers should use clinical judgment when aberrant drug-related
behaviors are observed. Such behavior should be reported to the proper authorities
and/or healthcare team as appropriate.
Aberrant drug-related behaviors broadly range from mildly problematic (such as
hoarding medications to have an extra dose during times of more severe pain) to
felonious acts (such as selling medication). These are any medication-related
behaviors that depart from strict adherence to a prescribed therapeutic plan of care.
Prescribers and dispensers should observe, monitor and take precautionary measures
when a patient presents aberrant drug-related behaviors such as:
●
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●
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●
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Requesting early and/or repeated refills
Presents at or from an emergency department seeking high quantities of a
prescription
Denied by other prescribers or dispensers
Presents what is suspected to be a forged, altered or counterfeit prescription.
Forging prescriptions
Stealing or borrowing drugs
Frequently losing prescriptions
Aggressive demand for opioids
Injecting oral/topical opioids
Unsanctioned use of opioids
Unsanctioned dose escalation
Concurrent use of illicit drugs
Failing a drug screen
Getting opioids from multiple prescribers
Recurring emergency department visits for chronic pain management*
Prescribers and dispensers should be alert for subjective behaviors such as being
nervous, overly talkative, agitated, emotionally volatile, and evasive, as these may be
signs of a psychological condition that may be considered in a treatment plan or could
suggest drug misuse.**
*“Interagency Guidelines on Opioid Dosing for Chronic Non-Cancer Pain” State of
Washington Agency Medical Directors Group. 2010 Online:
http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf
**Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain. Sunrise River Press,
North Branch, MN 2007.
Practitioner Considerations
Healthcare team:
Consider that the patient may be receiving opioids from another prescriber. Contact
the patient’s healthcare team when appropriate which may include the following:
● Physician
● Specialist (pain, addiction, etc.)
● Dentist
● Advanced Practice Nurse (APN)
● Physician assistant
● Pharmacists
● Area emergency rooms
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●
Surrounding (within 5 miles) or historical pharmacies
Authorities:
●
●
If the prescriber or dispenser suspects illegal activity, the matter
should be referred to the Drug Enforcement Agency (DEA) and local law
enforcement.
If a prescriber or dispenser suspect illegal activity on behalf of another
prescriber or dispenser, at a minimum, the matter should be reported
to the appropriate licensing board.
Prescribers and dispensers should be aware that:
●
There is no legal obligation to prescribe or dispense a prescription;
and,
●
Colorado law strongly encourages prescribers and dispensers of opiate
antagonists “to educate persons receiving the opiate antagonist on the
use of an opiate antagonist for overdose, including but not limited to
instructions concerning risk factors for overdose, recognition of
overdose, calling emergency medical services, rescue breathing and
administration of an opiate antagonist.” (Section 18-1-712(3)(b),
C.R.S.)
Additional Resources and Tools
Establishing and maintaining competence:
Tenney, Lili and Lee Newman. “The Opioid Crisis: Guidelines and Tools for Improving
Pain Management” Center for Worker Health and Environment, Colorado School of
Public Health.
Functional and pain assessment:
“Functional Assessment” Colorado Division of Workers Compensation
Patient agreements:
“Screener and Opioid Assessment for Patients with Pain - Revised (SOAPP - R)”
PainEDU.org Online at: www.painedu.org
Pain tool kit:
Various resources for assessing and managing pain including risk assessments, patient
agreements, dose and conversion calculators among others.
Center for Worker Health and Environment, Colorado School of Public Health. Online
at:
http://www.ucdenver.edu/academics/colleges/PublicHealth/research/centers/maper
c/online/Pages/Pain-Management-CME.aspx
Substance use screening and brief counseling:
SBIRT Colorado
www.ImprovingHealthColorado.org
Drug abuse resources:
Substance Abuse and Mental Health Services Administration: www.samhsa.gov
NIH National Institute on Drug Abuse: www.drugabuse.gov or www.nida.nih.gov
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40-27
Guidelines for the Appropriate Use of Telehealth Technologies in the
Practice of Medicine
Date Issued:
Date(s) Revised:
8/20/15
Purpose:
To provide guidance regarding the appropriate use of telehealth technologies
in the practice of medicine.
Policy: The Colorado Medical Board (“Board”) has adopted the following guidelines for
providers utilizing telehealth technologies in the delivery of patient care.
I.
Introduction
The advancements and continued development of medical and communications technology offer
opportunities for improving the delivery and accessibility of health care, particularly in the area of
telehealth, which includes the practice of medicine using electronic communication, information
technology, or other means of interaction between a healthcare provider in one location and a patient in
another location with or without an intervening healthcare provider.6 The Colorado Medical Board
(“Board”) recognizes that using telehealth technologies in the delivery of medical services offers
potential benefits in the provision of medical care. However, in fulfilling its duty to protect the
public, the Board must also consider patient safety concerns in adapting rules and policies
historically intended for the in-person provision of medical care to new delivery models involving
telehealth technologies.
The Board is committed to assuring patient access to the convenience and benefits afforded by
telehealth technologies, while promoting the responsible practice of medicine by providers. The Board
has developed guidelines to educate licensees as to the appropriate use of telehealth technologies in
the delivery of medical services directly to patients. These guidelines do not set a standard of care, do
not alter generally accepted standards of medical practice, the scope of practice of any health care
provider, or authorize the delivery of health care services in a setting, or in a manner, not otherwise
authorized by law. It is the expectation of the Board that providers of medical care, electronically or
otherwise, maintain the highest degree of professionalism and should:
•
•
•
•
•
Place the welfare of patients first;
Maintain the generally accepted standards of medical practice;
Adhere to recognized ethical codes governing the medical profession;
Properly supervise non-physician clinicians; and,
Protect patient confidentiality.
This policy does not apply to the use of telehealth technologies when solely providing consulting
services to another provider who maintains the primary provider-patient relationship with the patient,
the subject of the consultation.
6
See Center for Telehealth and eHealth Law (Ctel), http://ctel.org/
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II.
Definitions
For the purpose of this policy, the following terms are defined as:
A.
"TELEHEALTH"
1. “Telehealth” means a mode of delivery of health care services
through telecommunications systems, including information,
electronic, and communication technologies, to facilitate the
assessment, diagnosis, consultation, treatment, education, care
management, or self-management of a person's health care while the
person is located at an originating site and the provider is located at a
distant site. The term includes synchronous interactions and storeand-forward transfers.
2. “Telehealth” includes “Telemedicine” as defined in section 12-36102.5(8), C.R.S.
3. This policy defines “telehealth” for purposes of compliance with the
Medical Practice Act. Telehealth may be defined differently in
different statutory contexts, including but not limited to, insurance
requirements or reimbursement.
B. “TELEHEALTH TECHNOLOGIES” means technologies and devices enabling
secure electronic communications and information exchange between a
licensee in one location and a patient in another location with or without
an intervening healthcare provider.
C. "DISTANT SITE" means a site at which a provider is located while providing
health care services by means of telehealth.
D. "ORIGINATING SITE" means a site at which a patient is located at the time
health care services are provided to him or her by means of telehealth.
E.
“STORE-AND-FORWARD TRANSFER" means the electronic transfer of a
patient's medical information or an interaction between providers that
occurs between an originating site and distant site when the patient is not
present.
F.
"SYNCHRONOUS INTERACTION" means a real-time interaction between a
patient located at the originating site and a provider located at a distant
site.
G. “PROVIDER” means a licensee regulated by the Colorado Medical Board.
H. “PROVIDER-PATIENT RELATIONSHIP” means the relationship as defined in
Board Policy 40-3.
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III.
Guidelines
A.
Licensure
Providers who evaluate, treat or prescribe through telehealth technologies are
practicing medicine. The practice of medicine occurs where the patient is
located at the time telehealth technologies are used. Therefore, a provider
must be licensed to practice medicine in the state of Colorado in order to
evaluate or treat patients located in Colorado utilizing telehealth technologies or
otherwise.
B.
Establishment of a Provider-Patient Relationship
Where an existing provider-patient relationship is not present, a provider must
take appropriate steps to establish a provider-patient relationship consistent
with the guidelines identified in Board Policy 40-3.
Provider-patient
relationships may be established using telehealth technologies so long as the
relationship is established in conformance with generally accepted standards of
practice.
C.
Evaluation and Treatment of the Patient
An appropriate medical evaluation and review of relevant clinical history,
commensurate with the presentation of the patient to establish diagnoses and
identify underlying conditions and/or contra-indications to the treatment
recommended/provided, s hould be performed prior to providing treatment,
including issuing prescriptions, electronically or otherwise. Treatment and
consultation recommendations made in an online setting, including issuing a
prescription via electronic means, will be held to the same standards of
appropriate practice as those in traditional (encounter in person) settings.
Treatment, including issuing a prescription based solely on an online
questionnaire, does not constitute an acceptable standard of care.
D.
Informed Consent
Appropriate informed consent should be obtained for a telehealth encounter
including those elements required by law and generally accepted standards of
practice.
E.
Continuity of Care
Physicians should adhere to generally accepted standards of medical practice as it
relates to continuity and coordination of care.
F.
Referrals for Emergency Services
An emergency plan should be provided by the provider to the patient when the
care provided using telehealth technologies indicates that a referral to an acute
care facility or Emergency Department for treatment is necessary for the safety of
the patient.
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G.
H.
Medical Records
The medical record should include, if applicable, copies of all patient-related
electronic
communications,
including
patient-provider
communication,
prescriptions, laboratory and test results, evaluations and consultations, records
of past care, and instructions obtained or produced in connection with the
utilization of telehealth technologies. Informed consents obtained in connection
with an encounter involving telehealth technologies should also be filed in the
medical record. The patient record established during the use of telehealth
technologies must be accessible and documented for both the provider and the
patient, consistent with all established laws and regulations governing patient
healthcare records.
Privacy and Security of Patient Records & Exchange of Information
Providers should meet or exceed applicable federal and state legal requirements
of medical/health information privacy, including compliance with the Health
Insurance Portability and Accountability Act (HIPAA) and state privacy,
confidentiality, security, and medical record retention rules.
Written policies and procedures should be maintained at the same standard as
traditional in-person encounters for documentation, maintenance, and
transmission of the records of the encounter using telehealth technologies.
I.
Disclosures and Functionality for Providing Online Services
Disclosures and advertising should be made in accordance with state and federal
law.
J.
Prescribing
Prescribing medications, in-person or via telehealth technologies, is at the
professional discretion of the provider. The indication, appropriateness, and
safety considerations for each telehealth visit prescription must be evaluated by the
provider in accordance with current standards of practice and consequently carry
the same professional accountability as prescriptions delivered during an
encounter in person. However, where such measures are upheld, and the
appropriate clinical consideration is carried out and documented, providers may
exercise their judgment and prescribe medications as part of telehealth
encounters.
The recommendation of medical marijuana via telehealth technologies is
prohibited.
K.
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Parity of Professional and Ethical Standards
There should be parity of ethical and professional standards applied to all aspects
of a provider’s practice.
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A provider’s professional discretion as to the diagnoses, scope of care, or
treatment should not be limited or influenced by non-clinical considerations of
telehealth technologies, and provider remuneration or treatment recommendations
should not be materially based on the delivery of patient-desired outcomes (i.e. a
prescription or referral) or the utilization of telehealth technologies.
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40-28
Policy Regarding Recommendations for Marijuana as a Therapeutic Option
Date Issued:
Date(s) Revised:
November 19, 2015
Purpose:
To provide guidelines for Colorado physicians who recommend marijuana for
medical use.
INTRODUCTION: Section 12-36-141 of the Colorado Revised Statutes, enacted by Senate Bill 15-014,
provides that the Board, in consultation with the Colorado Department of Public Health and
Environment (“CDPHE”) and physicians specializing in medical marijuana, shall establish guidelines for
physicians making medical marijuana recommendations. The Board, having made such consultation in
noticed public meetings and following consideration of input from stakeholders, adopts the following
guidelines.
Nothing in these guidelines alters a physician’s obligation to comply with all applicable laws relating to
medical marijuana or limits the State’s regulation of the practice of medicine.
POLICY: It is the policy of the Colorado Medical Board that the recommendation of marijuana as a
therapeutic option constitutes the practice of medicine. These guidelines do not set a standard of care
and are neither intended as an endorsement of marijuana as a therapeutic option, nor are they
designed to create an undue burden to those who recommend marijuana as a therapeutic option.
Rather, this policy serves to provide guidance to a physician caring for a patient with one or more
debilitating conditions for which marijuana is being considered as a therapeutic agent.
When considering the recommendation of marijuana as a therapeutic option, a physician should
observe the following guidelines:
A. Compliance with Law
Physicians engaged in the recommendation of marijuana as a therapeutic option must adhere
to applicable law, including but not limited to, section 14 of article XVIII of the state
Constitution, sections 12-36-117(1) and 25-1.5-106 of the Colorado Revised Statutes (“C.R.S.”),
Colorado Department of Public Health and Environment (“CDPHE”) rules promulgated pursuant
to section 25-1.5-106(3), and generally accepted standards of medical practice.
B. Develop and Maintain Competence
Physicians, who wish to engage in the recommendation of marijuana as a therapeutic option,
should develop and maintain competence in the evaluation, assessment, and treatment of the
relevant State approved debilitating conditions for which marijuana is permitted as a
therapeutic option.
Competence, for the purpose of this policy, includes understanding current, evidenced-based
practices and using other resources and tools related to evaluating patients and recommending
marijuana as a therapeutic option.
C. Physician-Patient Relationship
A bona-fide physician-patient relationship as defined in CDPHE Regulation 8.A.2 (5 CCR 1006-2)
and Board Policy 40-3 must exist prior to any recommendation for marijuana as a therapeutic
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option.
D. Setting
Any recommendation for marijuana as a therapeutic option must be made during an in-person
encounter in a clinical setting. Recommendations for marijuana as a therapeutic option via
telehealth are prohibited. See CDPHE Regulation 8.A.2(c)(5 CCR 1006-2).
E. Evaluation
Prior to making a recommendation for marijuana as a therapeutic option, the physician must
evaluate the patient. This evaluation should include:
1. Patient History
The patient history should include a history of the present illness as well as past
medical/surgical history, medication history and relevant social, family, and mental
health history.
2. Physical Examination
An appropriate physical examination should be performed in accordance with generally
accepted standards of medical practice.
3. Patient Assessment
As with all medical practice, the physician should integrate the patient history,
physical examination findings, pertinent laboratory and imaging data, review of prior
medical records and/or consultation(s) with other providers to render an informed
diagnosis.
Should the physician render a diagnosis of a qualifying debilitating medical condition,
the physician may subsequently counsel the patient regarding the pros, cons, risks,
benefits, alternatives and other relevant considerations around a recommendation for
marijuana as a therapeutic agent. Additional considerations around such a
recommendation may include, but are not limited to: a personal or family history of
substance use (including alcohol, prescriptions drugs, opioids, and marijuana); the
patient’s medication history (including potential drug-drug interactions); co-morbid
medical conditions; mental health/psychological conditions; and, evidence of adverse
medical, psychological or behavioral reactions to marijuana.
For those patients for whom the qualifying debilitating medical condition is severe
pain, a targeted but detailed pain assessment should be performed. Such evaluation
may include, but is not limited to, the nature, intensity, pattern/frequency, duration
and physical and psychological impact of the pain. Past and current treatments and
co-morbid conditions should also be taken into consideration. Where appropriate,
physicians should utilize the Prescription Drug Monitoring Program (“PDMP”).
For women of child-bearing age, the recommending physician should also take into
consideration the possibilities of pregnancy and breast-feeding and perform further
evaluation and/or counseling as appropriate.
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F. Diagnosis
Physicians should establish, ascertain, or confirm a diagnosis of a qualifying debilitating
medical condition appropriate for marijuana therapy through his or her history, physical
examination, assessment, or consultation with current or previous treating physicians and/or
review of patient medical records.
G. Treatment Recommendations
When considering a recommendation of marijuana as a therapeutic option, the physician should
consider all relevant factors that may reasonably be expected to weigh into the decision
around such a recommendation including alternative therapeutic options, potential benefits of
use, contraindications and potential risks of use along with other elements that the physician
and patient consider relevant to the decision making.
H. Patient Education
Physicians should educate their patients regarding administration and dosing, risks, benefits,
alternative therapeutic options, proper storage and disposal of marijuana, and the potential for
diversion. Risks may include, but are not limited to: overdose, misuse, diversion, addiction,
physical dependence and tolerance, interactions with other medications or substances,
impairment while driving or operating machinery, or other adverse reactions.
I.
Monitoring and Follow-up
Physicians recommending marijuana as a therapeutic option for their patients must be
available for patient follow-up and should monitor the patient, as feasible, on an ongoing basis
for efficacy, drug interactions, adverse reactions, and improved function.
J. Collaboration with other Healthcare Providers
Where possible, physicians recommending marijuana as a therapeutic option for their patients
should collaborate with that patient’s other healthcare providers to ensure and promote a
collaborative, coordinated, approach to patient care. While not feasible in all cases, the
recommending provider should follow generally accepted standards of medical practice in
regards to communications with other providers.
When confidentiality considerations
represent a compelling mitigating consideration around open and regular communication, such
considerations should be documented accordingly.
K. Documentation
A medical record should be created and maintained for each patient evaluated for marijuana
as a therapeutic option.
The record should, at a minimum, contain documentation of each physician-patient encounter;
an appropriate medical history; an appropriate physical examination; documentation of the
patient diagnoses, including the patient’s qualifying debilitating medical condition; patient
education; the patient’s longitudinal plan of care; and, a signed copy of the State required
certification form.
Additional elements that should be documented as appropriate to the patient’s individual
medical condition and plan of care may include: laboratory data and radiographic imaging; a
risk assessment; the physician’s review of previous medical records; communications from
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PRACTICE POLICIES, STATEMENTS & GUIDELINES
other providers and consultants; and, documentation of prior treatment modalities with
outcomes.
For patients who, in the opinion of the physician, require an increased marijuana plant count,
the medical record must clearly reflect the detailed rationale for the increased plant count.
Such rationale should incorporate and be supported by the findings on physical examination,
patient assessment, patient diagnosis, and the patient’s longitudinal plan of care as previously
set forth in this policy.
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Practice Policies, Statements & Guidelines
POLICY NUMBER:
Title:
Date Issued:
Date(s) Revised:
Reference:
Purpose:
40-29
Board Actions to Protect the Public Related to Drug Diversion and
Impaired Licensees
11/17/16
To provide guidance regarding the Board’s position related to
Drug Diversion and Impaired Practitioners
Policy: This policy provides guidance to licensees and notice to the public that, consistent with the Medical
Practice Act, the Board will take expedient action to protect the public by suspending a license or seeking a
cessation of practice agreement in instances where suspected drug diversion, or working while impaired by a
licensee, causes the potential for public harm. Such instances include, but are not limited to, the following:


Licensee is terminated for diversion. For the purposes of this policy, the Board will
consider resignation in lieu of termination to be a termination;
Licensee fails to submit to a drug test ordered by their employer;

Licensee is found to be working while impaired;

Self-disclosure of drug diversion by a licensee;

Notification to the board from law enforcement that licensee is suspected of drug diversion;

Pharmacy monitoring or surveillance that identifies suspicious activity for diversion of a
controlled substance by a licensee; or
Drug Diversion by a licensee witnessed by a credible source.

Other instances of drug diversion may warrant expedient action as well. The board retains the
discretion, as well as the responsibility, to consider the specific facts and circumstances of each
case.
It shall be the policy of the board to ensure a timely response and to take expedient action when
warranted pursuant to its authority if objective and reasonable grounds exist. Expedient action
includes summary suspension and cessation of practice agreements.
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