Common Contracts

Contract

February 27th, 2018

• Filed
  February 27th, 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. If the PA in question has prescriptive authority, a copy must also be submitted to the Board of Pharmacy. The Delegation Agreement must be signed by both the physician assistant and supervising physician. DELEGATION AGREEMENT FORMS WILL ONLY BE ACCEPTED VIA EMAIL OR REGULAR MAIL.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: Departme