American Health Network of Indiana, LLC
(Location address)
Supervisory Agreement for Physician Assistant
As required by Indiana statute, a licensed physician assistant must have a practice agreement with a licensed physician approved by the Medical Licensing Board of Indiana after review by the Physician Assistant Committee prior to beginning practice.
Physician Assistant Name
Physician Assistant License Number
Address:
Phone:
SUPERVISING PHYSICIAN(S)
Physician Name:
Physician License Number:
Address:
Phone:
Additional entries, if necessary, are included in Exhibit A (Other Supervising Physicians)
SCOPE OF PRACTICE
The physician assistant is delegated to perform the following tasks and procedures that are within the physician assistant’s education and training and the supervising physician’s scope of practice:
See Exhibit B (Scope of Practice).
LOCATION OF SERVICES
The physician assistant will be providing the services below described settings (description and address):
1.
2.
3.
4.
5.
EMERGENCY PROCEDURES
The physician assistant will follow the procedure described below for dealing with emergencies:
Call 911 Emergency Center and then the patient’s attending physician.
MEDICATIONS
A physician assistant may prescribe medications included in the supervising physician’s scope of practice as delegated by the supervising physician. The classifications of drugs delegated may not include Schedule I, and II medications or Schedule III-V medications containing oxycodone. Please list the classifications of medications the Physician Assistant is delegated to prescribe:
See Exhibit C - Classifications of Medications Physician Assistant May Prescribe
A supervising physician must describe the protocols to be used for the Physician Assistant prescribing. This may include clinical practice guidelines, referenced texts or other sources. Describe the protocols to be used in your practice:
See Exhibit B (Scope of Practice).
TRAINING
A Physician Assistant may be delegated ability to prescribe if the Physician Assistant has completed 30 contact hours of instruction in pharmacology. Attach verification of 30 hours of pharmacology from an accredited Physician Assistant program of Category I CME activity.
A Physician Assistant may be delegated ability to prescribe if the Physician Assistant has one year of work experience as a practicing physician assistant. (This is defined as a minimum of 1800 hours of practice.)
See Exhibit D (Documentation of CME and Work Experience)
Sign and date this form.
______PA MD or DO
______Date Date
MD or DO
Date
MD or DO
Date
(Include additional supervising physicians if needed.)
Exhibit A Other Supervising Physicians
Physician Name:
Physician License Number:
Address:
Phone:
Physician Name:
Physician License Number:
Address:
Phone:
Physician Name:
Physician License Number:
Address:
Phone:
Physician Name:
Physician License Number:
Address:
Phone:
Physician Name:
Physician License Number:
Address:
Phone:
Exhibit B Scope of Practice
Name of Physician Assistant: ______
LETTER HEAD of Practice Location
Under the continuous supervision of Dr. ______(Name of Doctor) or a physician designee, (Name of Physician Assistant) will:
1. Perform complete comprehensive history and physical assessments.
2. Determine medical diagnosis and manage acute and chronic health problems.
3. Order, perform and interpret laboratory tests, diagnostic and invasive procedures as appropriate.
4. Following physician observation and approval of technique, perform therapeutic or corrective measures, including but not limited to, suturing, incision and drainage, sebaceous cyst removal, benign lesion removal and toenail removal.
5. Refer patients to appropriate specialists, services and community resources, (i.e. therapy and social services.)
6. May help provide and conduct hospital admissions, contingent upon appropriate hospital clinical privileges.
7. Provide and conduct nursing home admissions and follow-up care.
8. Provide emergency care in collaboration with the physician.
9. Provide preventative care and counseling on health and awareness related conditions.
10. Prescribe medications consistent with clinical practice guidelines in the Supervising Physician’s office and local practice. In the event of any unusual condition or questions regarding medications the Physician Assistant will consult with Supervising Physician prior to prescribing. In prescribing medications, I will examine potential indications and contraindications of the medication, while noting any patient allergies, drug interactions, and the proper dosage for the patient. I will also take into account the weight of a child prior to prescribing the appropriate dosage of a medication. I will consult with my supervising physician as needed, on a case-by-case basis. No controlled substances will be prescribed prior to obtaining a DEA number.
Supervision of the physician assistant will be continuous, although this will not require the physical presence of the supervising physician at the time and the place that the services are rendered. The supervising physician or physician designee shall review all patient encounters not later than twenty-four hours after the physician assistant has seen the patient.
______
Signature or Supervising Physician Doctor Date
Exhibit C. Classifications of Drugs which Physician Assistant May Prescribe
Name of Physician Assistant: ______
LETTER HEAD of Practice Location
The physician assistant may prescribe medications included in the supervising physician’s scope of practice.
Check all categories that are approved to be prescribed by the above named Physician Assistant
1. ___ Allergy
2. ___ Analgesics
3. ___ Anti Anxiety
4. ___ Anti Inflammatory
5. ___ Antibiotic
6. ___ Anti Depressant
7. ___ Anti Fungal
8. ___ Antipsychotic
9. ___ Antiviral
10. ___ Arthritis
11. ___ Asthma
12. ___ Cardiac
13. ___ Cholesterol
14. ___ Cough/Cold
15. ___ Diabetes
16. ___ Gastrointestinal
17. ___ Gingivitis
18. ___ Glaucoma Eye
19. ___ Hormone
20. ___ Incontinence
21. ___ Oncology/Cancer
22. ___ Parkinson’s
23. ___ Seizure
24. ___ Thyroid
25. ___ Vitamins
26. ___ Other(s) (specify ______)
Supervising Physician’s Signature: ______
Date: ______
Exhibit D. Documentation of Physician Assistant of CME and Work Experience
To Whom It May Concern:
Physician Assistant (Name) ______has had one year or more work
experience as a practicing physician assistant.
Name of Supervising Physician: ______
Signature of Supervision Physician ______
Date: ______
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AHN PA Supervisory Agreement 7-13-07