"Substance Use Disorder Clinic Supervising Provider Attestation Form" - Colorado

Substance Use Disorder Clinic Supervising 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 June 18, 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 printable 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.

ADVERTISEMENT
ADVERTISEMENT

Download "Substance Use Disorder Clinic Supervising Provider Attestation Form" - Colorado

221 times
Rate (4.4 / 5) 15 votes
Revised: 06182018
Substance Use Disorder Clinic Supervising Provider Attestation
Provider Type 64, Specialty 477
Clinic/Billing entity name:
Clinic/Billing entity NPI:
Supervising practitioner name:
Supervising practitioner NPI:
Supervising practitioner credentials (select all that apply):
Health First Colorado-enrolled licensed health practitioners who are:
Advanced Practice Nurses,
Physicians/Psychiatrists, or
Physician Assistants
AND one of the following:
Certified in addiction psychiatry by the American Board of Psychiatry and Neurology
(ABPN); or
Certified as National Certified Addiction Counselors II (NCAC II) or Master Addiction
Counselors (MAC) by the National Association of Alcohol and Drug Abuse Counselors
(NAADAC); or
Certified as Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction
Counselors (LAC) by the Department of Regulatory Agencies (DORA); or
Certified in addiction medicine by the American Society of Addiction Medicine (ASAM), the
American Board of Addiction Medicine (ABAM), or the American Board of Preventive Medicine
(ABPM); or
Health First Colorado-enrolled licensed behavioral health clinicians who are:
Psychologists (PhD, PsyD, or EdD),
Licensed Clinical Social Workers (LCSW),
Licensed Professional Counselors (LPC),
Licensed Marriage and Family Therapists (LMFT), or
Licensed Addiction Counselors (LAC)
Supervising practitioner license number:
Supervising practitioner license expiration date:
Evidence of supervising practitioner license and credentials: (upload 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
Revised: 06182018
Substance Use Disorder Clinic Supervising Provider Attestation
Provider Type 64, Specialty 477
Clinic/Billing entity name:
Clinic/Billing entity NPI:
Supervising practitioner name:
Supervising practitioner NPI:
Supervising practitioner credentials (select all that apply):
Health First Colorado-enrolled licensed health practitioners who are:
Advanced Practice Nurses,
Physicians/Psychiatrists, or
Physician Assistants
AND one of the following:
Certified in addiction psychiatry by the American Board of Psychiatry and Neurology
(ABPN); or
Certified as National Certified Addiction Counselors II (NCAC II) or Master Addiction
Counselors (MAC) by the National Association of Alcohol and Drug Abuse Counselors
(NAADAC); or
Certified as Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction
Counselors (LAC) by the Department of Regulatory Agencies (DORA); or
Certified in addiction medicine by the American Society of Addiction Medicine (ASAM), the
American Board of Addiction Medicine (ABAM), or the American Board of Preventive Medicine
(ABPM); or
Health First Colorado-enrolled licensed behavioral health clinicians who are:
Psychologists (PhD, PsyD, or EdD),
Licensed Clinical Social Workers (LCSW),
Licensed Professional Counselors (LPC),
Licensed Marriage and Family Therapists (LMFT), or
Licensed Addiction Counselors (LAC)
Supervising practitioner license number:
Supervising practitioner license expiration date:
Evidence of supervising practitioner license and credentials: (upload 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