DR 0366 (07/18/22) 
                                                COLORADO DEPARTMENT OF REVENUE
                                                Tax.Colorado.gov
*DO=NOT=SEND*

    Rural & Frontier Health Care Preceptor Credit
                                                Instructions

Health care professionals who provide a preceptorship                ● Pharmacist
during the tax year may be eligible for the Rural and                ● Licensed Clinical or Counseling Psychologist
Frontier Health Care Preceptor tax credit. The following 
                                                                     ●
Colorado license types qualify for this credit:                        Licensed Clinical Social Worker
                                                                     ● Licensed Professional Counselor 
  ● Doctor of Medicine
                                                                     ● Licensed Marriage and Family Therapist
  ● Doctor of Osteopathic Medicine
                                                                     ● Psychiatric Nurse Specialist
  ● Advanced Practice Nurse
                                                                     ● Licensed Addiction Counselor 
  ● Physician Assistant
                                                                     ● Certified Addiction Counselor Working in an 
  ● Doctor of Dental Surgery                                           Outpatient Clinical Setting
  ● Doctor of Dental Medicine                            Enter your license from the above list in the “Colorado 
  ● Registered Nurse                                     License Type” field on the DR 0366. See the DR 0366 for 
  ● Registered Dental Hygienist                          more instructions on claiming this credit. 

                                                    DR 0366 (07/18/22) 
                                                    COLORADO DEPARTMENT OF REVENUE
                                                    Tax.Colorado.gov
*230366==19999*                                     Page 1 of 1

                      2023 Rural & Frontier                                                                  SSN or ITIN

                  Health Care Preceptor Credit
Preceptor’s Last Name                               Preceptor’s First Name                                              Middle Initial

Preceptor’s Email                                              Preceptor’s Phone

Colorado License Type (see instructions)

Name of Preceptor’s Practice and Location

Address

City                                                County                                                   State ZIP

Only 300 primary health care preceptors are entitled to claim this credit each tax year. In order to claim this credit, the 
preceptor must:
i.  Receive certification that the preceptor satisfied all requirements to receive the credit from the institution for 
     which the preceptor teaches, whether it is an institution of higher education or a hospital, clinic, or other medical 
     facility, or from the regional AHEC office with jurisdiction over the area in which the preceptorship took place.
ii.  Send an electronic copy of the completed certification to the Department by email to dor_preceptor@state.co.us.
iii. If the preceptor receives notification from the Department that the credit has been issued to him or her, file a 
     Colorado income tax return and claim the credit on his or her return.

If applicable, Colorado AHEC Location  

Students Preceptored – Include Name, School, Program Name, Dates of Clinical Rotation, Dates of Preceptorship

By executing this form, I certify that during the income tax year the taxpayer satisfied all requirements to receive the credit.
Signature of Person Authorized to Certify the Credit