One (1) year experience working with individuals with paralysis or other long-term physical disabilities.Īdapted Therapeutic Recreational Equipment/Fees - CES.One (1) year of experience providing Acupuncture services at the rate of 520 hours per year.A resume for each individual providing services that demonstrates the following experience:.A DORA Acupuncturist license for each individual providing services.Must include account and routing numbers.If bank letter is submitted, the letter must be signed by the bank within the last six months.Voided check or bank letter address must match an address on the application.DBA (Trade Name) must be listed on Line 2 if included on the application.Address must match one address listed on the application.Copy of W-9 signed within last six months.However, proof of insurance is not a required attachment. Malpractice/Liability insurance information must be entered on the application.Affidavit of Lawful Presence can be found on the HCPF Provider Services website under "Provider Forms".Driver License) must be attached to application Photocopy of government issued photo ID (i.e.Copy of the Affidavit of Lawful Presence for SSN enrollments only.SS-4 Employer Identification Number Assignment.Copy of one of the following IRS documents for EIN enrollments only.HCBS Service Provided Acupuncture Complementary and Integrative Health (CIH) When selecting multiple specialties, select all appropriate specialties/services on the same application. To contact CDPHE to submit a Letter of Intent go to then click "get licensed or certified", then "submit letter of intent". Please also be sure to review each of the specialties/services below for all requirements, including whether you are required to contact the Colorado Department of Public Health and Environment for additional requirements or approvals. Additional office locations, where no services are provided to members, do not need to be enrolled. In instances where services are provided in a Health First Colorado or Child Health Plan Plus (CHP+) member's residence or other non-provider owned setting, providers will need to use their main office location as the service address. Unless otherwise noted below, each service location must be enrolled separately by submitting a separate application, and paying an additional application fee (if applicable).
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