TRANSPORT AND BACKUP. In a medical emergency, telephone the 911 operator to summon an ambulance. The emergency room at (Name of Hospital) (Phone Number) is to be notified that a patient with an emergency problem is being transported to them for immediate admission. Give the name of the admitting physician. Tell the ambulance crew where to take the patient and brief them on known and suspected health condition of the patient. Notify at immediately (Name of Physician) (Phone Number/s)) (or within minutes). PHYSICIAN ASSISTANT DECLARATION My signature below signifies that I fully understand the foregoing Delegation of Services Agreement, having received a copy of it for my possession and guidance, and agree to comply with its terms without reservations. Date Physician's Signature (Required) Physician's Printed Name Date Physician Assistant's Signature (Required) Physician Assistant's Printed Name SUPERVISING PHYSICIAN'S RESPONSIBILITY FOR SUPERVISION OF PHYSICIAN ASSISTANT SUPERVISOR , M.D./D.O. is licensed to practice in California as a physician and surgeon with medical license number . Hereinafter, the above named physician shall be referred to as the supervising physician.
TRANSPORT AND BACKUP. In a medical emergency, telephone the 911 operator to summon an ambulance. The emergency room at (Name of Hospital) (Phone Number) is to be notified that a patient with an emergency problem is being transported to them for immediate admission. Give the name of the admitting physician. Tell the ambulance crew where to take the patient and brief them on known and suspected health condition of the patient. Notify at immediately (Name of Physician) (Phone Number/s)) (or within minutes). PHYSICIAN ASSISTANT DECLARATION My signature below signifies that I fully understand the foregoing Delegation of Services Agreement, having received a copy of it for my possession and guidance, and agree to comply with its terms without reservations. Date Physician's Signature Physician's Printed Name Date Physician Assistant's Signature Physician Assistant's Printed Name SAMPLE ONLY DO NOT RETURN TO THE PAC SUPERVISING PHYSICIAN'S RESPONSIBILITY FOR SUPERVISION OF PHYSICIAN ASSISTANT SUPERVISOR , M.D./D.O. is licensed to practice in California as a physician and surgeon with medical license number . Hereinafter, the above named physician shall be referred to as the supervising physician. SUPERVISION REQUIRED. The physician assistant (PA) named in the attached Delegation of Services Agreement will be supervised by the supervising physician in accordance with these guidelines, set forth as required by Section 1399.545 of the Physician Assistant Regulations, which have been read by the physician whose signature appears below. The physician shall review, countersign, and date within seven (7) days the medical record of any patient cared for by the physician assistant for whom the physician's prescription for Schedule II medications was transmitted or carried out. REPORTING OF PHYSICIAN ASSISTANT SUPERVISION. Each time the physician assistant provides care for a patient and enters his or her name, signature, initials, or computer code on a patient's record, chart or written order, the physician assistant shall also enter the name of his or her supervising physician who is responsible for the patient. When the physician assistant transmits an oral order, he or she shall also state the name of the supervising physician responsible for the patient. MEDICAL RECORD REVIEW. One or more of the following mechanisms, as indicated below, by a check mark (x), shall be utilized by the supervising physician to partially fulfill his/her obligation to adequately supervise the actions of the phys...
TRANSPORT AND BACKUP. In a medical emergency, telephone the 911 operator to summon an ambulance. The Dominican Hospital emergency room at 000-000-0000 (Name of Hospital) (Phone Number) is to be notified that a patient with an emergency problem is being transported to them for immediate admission. Give the name of the admitting physician. Tell the ambulance crew where to take the patient and brief them on known and suspected health condition of the patient. Notify Xxxxxx Xxxxxx at 000-000-0000 immediately (Name of Physician) (Phone Number/s)) (or within 90 minutes). PHYSICIAN ASSISTANT DECLARATION My signature below signifies that I fully understand the foregoing Delegation of Services Agreement, having received a copy of it for my possession and guidance, and agree to comply with its terms without reservations. Date Physician's Signature (Required) Physician's Printed Name Date Physician Assistant's Signature (Required) Xxxxx Xxxxx Physician Assistant's Printed Name SUPERVISING PHYSICIAN'S RESPONSIBILITY FOR SUPERVISION OF PHYSICIAN ASSISTANT SUPERVISOR Xxxxxx Xxxxxx , M.D./D.O. is licensed to practice in California as a physician and surgeon with medical license number G87595 . Hereinafter, the above named physician shall be referred to as the supervising physician.
