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.
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.
Practice Location Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Scope of Practice for Nurse Practitioner*
Yes, prescriptive authority is includedNo, prescriptive authority is not included
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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