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44 Luxury Nurse Practitioner Collaborative Agreement Template
. sample collaborative practice agreement sample collaborative practice agreement this agreement sets forth the terms of the collaborative practice agreement between nurse practitioner and specialty as listed on the state issued certificate and name of collaborating physician and specialty if collaborative practice agreement template np assignment collaborative practice agreement assignment guidelines 1 collaborative practice agreement template np assignment guidelines this agreement sets forth the terms of the collaborative practice agreement between name of collaborative practice agreement for nurse practitioner the nurse practitioner is authorized to diagnose and prescribe under the collaborative agreement established in this document without the direct on site supervision or approval of the supervising physicians “example” collaborative practice agreement for advanced collaborative practice agreement for advanced practice nurses requesting prescriptive authority rule 848 iac 5 1 1 – initial authority to prescribe legend drugs 1 plete names home and business addresses zip codes and telephone numbers of the licensed practitioner and the advanced practice nurse licensed practitioner advanced practice nurse licensed practitioner name and license collaborative practice agreement for nurse practitioner this collaborative practice agreement will be reviewed revised if indicated and signed by the nurse practitioner and supervising physician on an annual basis g the collaborative practice agreement is not intended to be nor should it be a substitute for the exercise of professional judgment by the nurse practitioner