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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

253 9. Full and complete identifying information about any and all affiliations that a provider or any of its owning or managing employees or organizations has or, within the previous 5 years, had with a currently or formerly enrolled Medicare, Medicaid, or Children’s Health Insurance Program provider or supplier that has a disclosable event as defined at 42 C.F.R. § 455.101 (2024). 42 C.F.R. § 455.101 is hereby incorporated by reference. The incorporation of 42 C.F.R. § 455.101 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.ecfr.gov. Full and complete identifying information includes: a. Legal name as reported to the Internal Revenue Service or the Social Security Administration b. “Doing business as” name (if applicable) c. Tax identification number d. National Provider Identifier (NPI) e. Reason for disclosing the affiliated provider or supplier f. Specific data regarding the affiliation relationship, including: i. Length of relationship ii. Type of relationship iii. Degree of affiliation g. Reason for termination, if the affiliation has ended 8.125.15.B. Disclosures from any provider or disclosing entity are due at any of the following times: 1. Upon the provider or disclosing entity submitting the provider application.

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Page 253

Official source

CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

253 9. Full and complete identifying information about any and all affiliations that a provider or any of its owning or managing employees or organizations has or, within the previous 5 years, had with a currently or formerly enrolled Medicare, Medicaid, or Children’s Health Insurance Program provider or supplier that has a disclosable event as defined at 42 C.F.R. § 455.101 (2024). 42 C.F.R. § 455.101 is hereby incorporated by reference. The incorporation of 42 C.F.R. § 455.101 excludes later amendments to, or editions of the referenced material. Pursuant to § 24-4-103(12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at 303 E. 17th Ave., Denver, CO, 80203. Certified copies of incorporated materials are provided at cost upon request. Incorporated materials may also be obtained from the original issuer at www.ecfr.gov. Full and complete identifying information includes: a. Legal name as reported to the Internal Revenue Service or the Social Security Administration b. “Doing business as” name (if applicable) c. Tax identification number d. National Provider Identifier (NPI) e. Reason for disclosing the affiliated provider or supplier f. Specific data regarding the affiliation relationship, including: i. Length of relationship ii. Type of relationship iii. Degree of affiliation g. Reason for termination, if the affiliation has ended 8.125.15.B. Disclosures from any provider or disclosing entity are due at any of the following times: 1. Upon the provider or disclosing entity submitting the provider application.