Common Contracts
2 similar Delegation Agreement contracts
ContractDelegation Agreement • January 9th, 2018
PHYSICIAN ASSISTANT (PA) DELEGATION AGREEMENT FORM This document is to be filed with the Board of Medicine. A duplicate copy is to be kept on site at the primary place of practice. The Delegation Agreement must be signed by both the physician assistant and supervising physician.If you have any questions, you may email the Board of Medicine at dcbomed@dc.gov. SECTION 1: PHYSICIAN ASSISTANT First Name: MI: Last Name: Date of Birth: Gender: Male Female DC Lic. #: SECTION 2: SUPERVISING PHYSICIAN First Name: MI: Last Name: Date of Birth: Gender: Male Female DC Lic. #: SECTION 3: PRACTICE LOCATION(S) List ALL practice locations where the physician assistant(s) will be providing patient care. Use additional sheets if necessary. PRACTICE LOCATION #1 Practice Name: Practice Address: City: State: Zip Code: Department: Phone #: PRACTICE LOCATION #2 Practice Name: Practice Address: City: State: Zip Code: Department: Phone #: PRACTICE LOCATION #3 Practice Name: Practice Address: City: State: Zip
ContractDelegation Agreement • December 27th, 2017
PHYSICIAN ASSISTANT (PA) DELEGATION AGREEMENT FORM This document is to be filed with the Board of Medicine. A duplicate copy is to be kept on site at the primary place of practice. The Delegation Agreement must be signed by both the physician assistant and supervising physician.If you have any questions, you may email the Board of Medicine at dcbomed@dc.gov. SECTION 1: PHYSICIAN ASSISTANT First Name: MI: Last Name: Date of Birth: Gender: Male Female DC Lic. #: SECTION 2: SUPERVISING PHYSICIAN First Name: MI: Last Name: Date of Birth: Gender: Male Female DC Lic. #: SECTION 3: PRACTICE LOCATION(S) List ALL practice locations where the physician assistant(s) will be providing patient care. Use additional sheets if necessary. PRACTICE LOCATION #1 Practice Name: Practice Address: City: State: Zip Code: Department: Phone #: PRACTICE LOCATION #2 Practice Name: Practice Address: City: State: Zip Code: Department: Phone #: PRACTICE LOCATION #3 Practice Name: Practice Address: City: State: Zip
