Board of Medicine ARNP / EMT / Paramedic Protocol Form at a glance
What it is: The Board of Medicine ARNP / EMT / Paramedic Protocol Form is the notice a physician shall submit to the board.
Who signs: The physician signs in the Signature of Physician box.
When a physician enters into an established protocol with an Advanced Registered Nurse Practitioner, an Emergency Medical Tech (EMT) or a Paramedic, the physician shall submit notice to the board.
What to bring and attach to Board of Medicine ARNP / EMT / Paramedic Protocol Form
No additional documentation required.
A filled-in Board of Medicine ARNP / EMT / Paramedic Protocol Form example: a physician reports a new ARNP protocol
How to fill out Board of Medicine ARNP / EMT / Paramedic Protocol Form, box by box
Physician name, license number and practice location
After I, enter the name of the physician. Enter the license number after ME00 and the practice location.
Entered into or terminated the relationship
Mark entered into a or terminated my formal supervisor relationship, standing orders, or an established protocol with the amount of ARNP(s), EMT(s), Paramedic(s).
Name, license number and effective date
Print or type the name of the ARNP/EMT/Paramedic, the license number and the effective date.
Only one physician per form. Use extra sheets for additional ARNP's / EMT's / Paramedics.
Signature of Physician
The physician signs in the Signature of Physician box.
Common questions about Board of Medicine ARNP / EMT / Paramedic Protocol Form
Is there a deadline?
Notice shall be filed within 30 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. 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.
Where do I file it?
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.
Sources
[1] Form DH-MQA1069 (Revised 6/2013), ARNP / EMT / Paramedic Protocol Form, Florida Board of Medicine (the Official source link on this page).