Code of Colorado Regulations
700 - Department of Regulatory Agencies
749 - Division of Professions and Occupations - Office of Naturopathic Doctor Registration
4 CCR 749-1 - NATUROPATHIC DOCTORS RULES AND REGULATIONS
Appendix B - SAMPLE COLLABORATIVE AGREEMENT FOR THE TREATMENT OF CHILDREN UNDER TWO
The following parties agree to a collaborative arrangement in which the naturopathic doctor (ND) may consult with the Colorado licensed physician (pediatrician or family MD/DO) regarding patients under 2 years and refer to a physician. The purpose of this agreement is to facilitate the effective treatment of the patient.
Specific responsibilities of naturopathic doctor: ___________________________________________________________________________________
___________________________________________________________________________________
Specific responsibilities of licensed physician:
___________________________________________________________________________________
___________________________________________________________________________________
Process for consulting with licensed physician, including the means, e.g., in person, via phone, or via telehealth, and the frequency, e.g., per visit, on an as needed basis, or regularly scheduled on a weekly, monthly or quarterly basis):
___________________________________________________________________________________
___________________________________________________________________________________
Process for referring the patient to a licensed physician to facilitate the effective treatment of the child:
___________________________________________________________________________________
___________________________________________________________________________________
Emergency plan:
___________________________________________________________________________________
___________________________________________________________________________________
* This agreement does not limit the ability of the ND to make an independent judgment.
* This agreement does not require medical supervision of the ND by the physician.
* Neither party assumes liability for the actions of the other.
* The above parties do not have to be practicing in close proximity to one another.
* This agreement will be kept on file in both parties' respective patient file.
Naturopathic Doctor:
Name: ______________________________________________________________________________
Practice name ________________________________________________________________________
Address: ____________________________________________________________________________
Phone number: _________________________________ Cell number: __________________________
Fax: ________________________________________________________________________________
Email: ______________________________________________________________________________
Registration #: ________________________________________________________________________
Signature: ___________________________________________________________________________
Colorado Physician:
Name:______________________________________________________________________________
Practice name: _______________________________________________________________________
Add ress:_____________________________________________________________________________
Phone number: _________________________________Cell number:___________________________
Fax:________________________________________________________________________________
Email:_______________________________________________________________________________
License #:___________________________________________________________________________
Signature:___________________________________________________________________________
