COLORADO HEALTH CARE PROFESSIONAL CREDENTIALS APPLICATION A: The following information must be attached to this application: 1. The name and title of the person who is applying for the certificate. 2. The name of each professional education, nursing, paramedical and vocational degree that has been completed by the person who is applying for the certificate. 3. The address and telephone contact for contact in the application. 4. Proof of current identification and residency in the county in which the person intending to acquire the title of Colorado professional healthcare professional resides. 5. Proof of identity, if applicable. Any document of a Colorado professional shall not be accepted if it: (a) Is fake, (b) Is fictitious, or (c) Does not have the signature of the owner of the document. 6. Proof that the professional is currently engaged in the practice of professional healthcare services, as defined by section 12-36-102, C.R.S. Any concurrent certificate or license issued prior to July 1, 2015, that contains a certificate of competency issued by the board pursuant to section 12-36-102, C.R.S., shall be surrendered to the board upon entry. Any concurrent certificate or license issued on or after July 1, 2015, that contains a certificate of competency from the board pursuant to section 12-36-102, C.R.S., shall be surrendered to the board upon entry unless the board finds that any of the following apply: (a) The certificate or license has expired or was surrendered more than thirty (30) months prior to the date of application. (b) The certificate or license was destroyed or destroyed with the certificate or license or a certified copy of the certificate or license was otherwise lost. © The certificate or license has been revoked for any reason. (d) The person who applied for the certificate or license has changed the professional name or professional registration number of the person's certificate or license pursuant to section 12-36-103, C.R.S., and the person seeking the certificate or license does not know or have any reliable information concerning the certificate or license.
CO 6 CCR 1014-4 2011 free printable template
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DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT State Board of Health 6 CCR 1014-4 COLORADO HEALTH CARE PROFESSIONAL CREDENTIALS APPLICATION Amended September 21 2011 effective October 30 2011 Adopted by the State Board of Health 09/21/11 effective 10/30/11 This is the Colorado healthcare professional credentials application. The Colorado legislature has mandated that all health care entities and all health care plans engaged in the collection of information to be used in the process of...
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