APPROVAL STATEMENT. Having read and understood the full contents of this Agreement, the parties hereto agree to be bound by its terms. Primary Supervising Physician signature: __________________ Date: Supervising Physician typed name: Advanced Practice Provider signature: _____________________Date: APP typed name: BACK-UP SUPERVISING PHYSICIAN(S) FORM Name of Advanced Practice Provider: Please keep a copy of this form on file at all practice sites for which it applies as part of the inspectable supervisory arrangements statement. DO NOT send this form to the NCBON/NCMB. *Signature of Primary Supervising Physician (PSP): ________________Date: *must be signed and dated after signatures of backup MDs completed *Signature of Advanced Practice Provider: _______________________Date: *must be signed and dated after signatures of backup MDs completed PSP APP Initials Initials Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ PSP APP Initials Initials Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervising MD name: Date: Signature: ______________________________________ Back-up supervisi...
APPROVAL STATEMENT. Having read and understood the full contents of this Agreement, the parties hereto agree to be bound by its terms. Primary Supervising Physician signature: _ Date: Supervising Physician typed name: Advanced Practice Providersignature: Date: APP typed name: BACK-UP SUPERVISING PHYSICIAN(S) FORM
APPROVAL STATEMENT. Having read and understood the full contents of this Agreement, the parties hereto agree to be bound by its terms. Primary Supervising Physician signature: ________________________Date: Supervising MD typed name: Advanced Practice Provider signature: __________________________Date: APP typed name: BACK-UP SUPERVISING PHYSICIAN(S) FORM Name of Advanced Practice Provider: Please keep a copy of this form on file at all practice sites for which it applies as part of the inspectable supervisory arrangements statement. DO NOT send this form to the NCBON. Signature of Primary Supervising Physician: ___________________ Date: Signature of Advanced Practice Provider: _____________________ Date: Back-up supervising physician: Date: Back-up supervising physician: Date: Back-up supervising physician: Date: Back-up supervising physician: Date: Back-up supervising physician: Date: Back-up supervising physician: Date: INITIAL APP and Supervising Physician Collaboration
