"Behavioral Therapy Provider Attestation Form" - Colorado

Behavioral Therapy Provider Attestation Form is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

  • Released on September 14, 2018;
  • The latest edition currently provided by the Colorado Department of Health Care Policy and Financing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Health Care Policy and Financing.

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09/14/2018
Behavioral Therapy Provider Attestation
Provider Type 84, Specialty 831
Provider name: _____________________________________________ NPI: ___________________________
I attest that I have licensing, credentials, experience and/or training as indicated below:
(check all that apply in the applicable section)
________________________________________________________________________________________
Doctoral degree with a specialty in psychiatry (PhD), medicine (MD) or clinical psychology (PhD) and am
actively licensed by the state board of examiners (attach a copy of the license) AND
have completed 400 hours of training and/or
have direct supervised experience in behavioral therapies that are consistent with best practice and
research on effectiveness for people with autism or other developmental disabilities.
________________________________________________________________________________________
Doctoral degree in one of the behavioral or health sciences (attach a copy of diploma or transcript) AND
have completed 800 hours of specific training and/or
experience in behavioral therapies that are consistent with best practice and research on effectiveness
for people with autism or other developmental disabilities.
________________________________________________________________________________________
Nationally certified as a Board Certified Behavior Analyst (BCBA). (Attach a copy of the certification. In
lieu of BCBA Certificate, a screen shot from the Behavioral Analyst Certification Board (BACB) website
indicating name, location, level, number, and valid date span is acceptable.)
________________________________________________________________________________________
Master’s degree or higher, in behavioral or health sciences (attach a copy of diploma or transcript) AND
licensed teacher with an endorsement of school psychologist (attach a copy of the license); or
licensed teacher with an endorsement of special education or early childhood special education
(attach a copy of the license); or
credentialed as a related services provider (Physical Therapist, Occupational Therapist, or Speech
Therapist. Attach a copy of the license.)
AND one of the following:
have completed 1,000 hours of direct supervised training or
experience in behavioral therapies that are consistent with best practice and research on
effectiveness for people with autism or other developmental disabilities.
________________________________________________________________________________________
Provider signature:
Evidence of license (if applicable) must be included
Evidence of training must be included: written documentation including dates, hours (with
total) and signature of supervisor
Evidence of behavioral therapy experience must be included: written documentation indicating
experience signed by supervisor
(upload all documents on ‘Attachments and Fees’ page of the Online Provider Enrollment application)
Our mission is to improve health care access and outcomes for the people we serve while demonstrating sound
stewardship of financial resources.
www.colorado.gov/hcpf
09/14/2018
Behavioral Therapy Provider Attestation
Provider Type 84, Specialty 831
Provider name: _____________________________________________ NPI: ___________________________
I attest that I have licensing, credentials, experience and/or training as indicated below:
(check all that apply in the applicable section)
________________________________________________________________________________________
Doctoral degree with a specialty in psychiatry (PhD), medicine (MD) or clinical psychology (PhD) and am
actively licensed by the state board of examiners (attach a copy of the license) AND
have completed 400 hours of training and/or
have direct supervised experience in behavioral therapies that are consistent with best practice and
research on effectiveness for people with autism or other developmental disabilities.
________________________________________________________________________________________
Doctoral degree in one of the behavioral or health sciences (attach a copy of diploma or transcript) AND
have completed 800 hours of specific training and/or
experience in behavioral therapies that are consistent with best practice and research on effectiveness
for people with autism or other developmental disabilities.
________________________________________________________________________________________
Nationally certified as a Board Certified Behavior Analyst (BCBA). (Attach a copy of the certification. In
lieu of BCBA Certificate, a screen shot from the Behavioral Analyst Certification Board (BACB) website
indicating name, location, level, number, and valid date span is acceptable.)
________________________________________________________________________________________
Master’s degree or higher, in behavioral or health sciences (attach a copy of diploma or transcript) AND
licensed teacher with an endorsement of school psychologist (attach a copy of the license); or
licensed teacher with an endorsement of special education or early childhood special education
(attach a copy of the license); or
credentialed as a related services provider (Physical Therapist, Occupational Therapist, or Speech
Therapist. Attach a copy of the license.)
AND one of the following:
have completed 1,000 hours of direct supervised training or
experience in behavioral therapies that are consistent with best practice and research on
effectiveness for people with autism or other developmental disabilities.
________________________________________________________________________________________
Provider signature:
Evidence of license (if applicable) must be included
Evidence of training must be included: written documentation including dates, hours (with
total) and signature of supervisor
Evidence of behavioral therapy experience must be included: written documentation indicating
experience signed by supervisor
(upload all documents on ‘Attachments and Fees’ page of the Online Provider Enrollment application)
Our mission is to improve health care access and outcomes for the people we serve while demonstrating sound
stewardship of financial resources.
www.colorado.gov/hcpf