Nurse Practitioner Practice Agreement

Nurse Practitioner Practice Agreement
Complete this form to establish a collaborative practice agreement between a nurse practitioner and a supervising physician or healthcare facility.
Nurse Practitioner Information
Please provide details about the nurse practitioner.
Full Name of Nurse Practitioner
First NameLast Name
Email Address of Nurse Practitioner
example@example.com
Phone Number of Nurse Practitioner
Please enter a valid phone number.Format: (000) 000-0000.
Supervising Physician/Facility Information
Please provide details about the supervising physician or healthcare facility.
Full Name of Supervising Physician or Facility Representative
First NameLast Name
Email Address of Supervising Physician or Facility
example@example.com
Phone Number of Supervising Physician or Facility
Please enter a valid phone number.Format: (000) 000-0000.
Practice Location Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Scope of Practice for Nurse Practitioner
Prescriptive Authority (if applicable)
Describe Supervision and Collaboration Arrangements
Communication Protocols (How and when will the nurse practitioner and supervising physician/facility communicate?)
Agreement Start Date
MonthDayYear
Date
Agreement End Date (if applicable)
MonthDayYear
Date
Signature of Nurse Practitioner
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Signature of Supervising Physician or Facility Representative
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