Arnp Florida Protocol Form PDF Details

In the medical field, collaboration and clear responsibilities are vital, particularly when it involves the interaction between physicians and Advanced Registered Nurse Practitioners (ARNPs), Emergency Medical Technicians (EMTs), and Paramedics in Florida. This dynamic is formalized through the "Board of Medicine ARNP / EMT / Paramedic Protocol Form," as stipulated under S. 458.348(1)(a), Florida Statutes. This crucial document is a cornerstone of medical practice in the state, setting the groundwork for an established protocol that allows for the delegation of specified medical acts. The protocol requires not only the identification and approval of these acts by a joint committee pursuant to s. 464.003(3)(c) and acts set forth in s. 464.012(3) and (4) but also mandates that physicians submit notice to the board, detailing the nature of the protocol established with an ARNP, EMT, or Paramedic. The form captures essential information, including the names and license numbers of the parties involved and the effective date of the agreement. It must be filed within thirty days of entering the relationship, any modifications to the protocol, or upon termination of said relationship, ensuring that all medical practices under these protocols are up-to-date and officially recognized. The strict time frame reinforces the importance of timely compliance and ensures that all protocols are current, reflecting any changes in scope of practice or partnership. The form, which requires no additional documentation for submission, streamlines the process, making it incumbent upon practicing physicians to maintain accurate and prompt records with the Department of Health, Board of Medicine in Tallahassee, either by mail or fax.

QuestionAnswer
Form NameArnp Florida Protocol Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesboard medicine protocol, florida protocol form, board medicine arnp, florida protocol

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Board of Medicine

ARNP / EMT / Paramedic Protocol Form

S. 458.348(1)(a), Florida Statutes, states in part, when a physician enters into an established protocol with an Advanced Registered Nurse Practitioner, an Emergency Medical Tech (EMT) or a Paramedic which protocol contemplates the performance of medical acts identified and approved by the joint committee pursuant to s. 464.003(3)(c) or acts set forth in s. 464.012(3) and (4), the physician shall submit notice to the board. The notice shall contain a statement in substantially the following form.

I,__,

(Please type or print name of physician)

license number ME00_______________of

__________________________________________________________________

(Please type or print practice location)

have hereby entered into a established protocol with

be filed within 30

(amount of)

terminated my formal supervisor relationship, standing orders, or an _ARNP(s), EMT(s), Paramedic(s). S. 458.348(1)(b), F.S. Notice shall

days of entering into the relationship, orders, or protocol. Notice also shall be provided within 30 days after the physician has terminated any such relationship, orders, or protocol.

 

__________

(Print or Type Name of ARNP/EMT/Paramedic)

 

(Print or Type Name of ARNP/EMT/Paramedic)

___________________________

___________________________

(License Number)

(License Number)

 

___________________________

(Effective Date)

(Effective Date)

__________________________________________________________________

(Signature of Physician)

Complete this form and return it to: Department of Health, Board of Medicine, 4052 Bald Cypress Way, BIN #C-03, Tallahassee, FL 32399-3253, or fax it to 850-488-0596. No additional documentation required. The protocol form must be filed with the Department within thirty (30) days of renewal of the ARNP’s license and any change to the protocol.

NOTE: Only one physician per form. Use extra sheets for additional ARNP’s / EMT’s / Paramedics.

DH-MQA1069 Rule 64B8-35.002 03/2003 Revised 6/2013

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