In today’s healthcare landscape, collaboration between professionals ensures that patient care is both comprehensive and efficient. Central to this teamwork in many healthcare settings is the Delegation of Services Agreement, particularly vital in contexts where physician assistants play a key role. This agreement, a document crafted jointly by the supervising physician(s) and the physician assistant, outlines the scope of services that the assistant is authorized to perform under the direction or oversight of the supervising physician. It’s a binding roadmap that not only facilitates a harmonious working relationship but also guarantees that the care provided aligns with the supervising physician’s scope of practice. Essential details such as the names and license numbers of the involved parties, practice sites, the extent and means of supervision, methods for immediate consultation, guidelines on chart review, and protocols on prescribing controlled substances are meticulously laid out. Importantly, this agreement, which must be available at each practice site and accessible upon request by the Division of Occupational and Professional Licensing (DOPL), illustrates a proactive approach to ensuring that a physician assistant’s practice is compliant, ethical, and responsive to the needs of patients. Moreover, it addresses procedures for scenarios outside the assistant’s scope, and for providing backup in emergencies, underscoring the depth of planning to sustain patient health, safety, and welfare without compromise. The Delegation of Services Agreement stands as a testament to the healthcare industry’s commitment to patient-centered care through effective delegation and supervision.
| Question | Answer |
|---|---|
| Form Name | Delegation Of Service Agreement Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | delegated, utah delegation of services agreement, onsite, jointly |
PHYSICIAN ASSISTANT
DELEGATION OF SERVICES AGREEMENT
A Delegation of Services Agreement is to be maintained at each practice site and is to be available to DOPL upon request. It consists of written criteria jointly developed by a physician assistant’s supervising physician and any substitute supervising physicians and the physician assistant that permits a physician assistant, working under the direction or review of the supervising physicians, to assist in the management of illnesses and injuries common to the physician’s scope of practice.
The following information must be legible. Use additional sheets if necessary.
DO NOT SUBMIT YOUR DELEGATION OF SERVICES AGREEMENTS TO DOPL WITH YOUR APPLICATION FOR LICENSURE.
Physician Assistant Name:
Supervising Physician Name:
Utah License Number:
Substitute Supervising Physician(s): |
|
|
Name: |
|
Utah License Number: |
Name: |
|
Utah License Number: |
Name: |
|
Utah License Number: |
Name: |
|
Utah License Number: |
PRACTICE SITE(S):
1.Name of Facility: Address:
City: |
|
State: |
|
Zip: |
2.Name of Facility:
Address:
City: |
|
State: |
|
Zip: |
DEGREE AND MEANS OF SUPERVISION:
The supervising physician shall provide supervision to the physician assistant to adequately serve the health care needs of the practice population and ensure that the patient’s health, safety, and welfare will not be adversely compromised. There shall be a method of immediate consultation by electronic means whenever the physician assistant is not under the direct supervision of the supervising physician. A physician assistant holding a temporary license may work only under 100% direct supervision. There shall be a method of immediate consultation by electronic means whenever the physician assistant is not under the direct supervision of the supervising physician.
FREQUENCY AND MECHANISM OF CHART REVIEW:
The degree of onsite supervision shall be outlined in the Delegation of Services Agreement maintained at the site of practice. Physician assistants may authenticate with their signature any form that may be authenticated by a physician signature.
PRESCRIBING OF CONTROLLED SUBSTANCES:
A physician assistant may prescribe or administer an appropriate controlled substance if the physician assistant holds a current Utah controlled substance license covering the appropriate schedules of controlled substances and a current DEA registration covering the appropriate schedules of controlled substances; the prescription or administration of the controlled substance is within the prescriptive practice of the supervising physician and also within the delegated prescribing stated in the delegation of services agreement; and the supervising physician
In order to prescribe controlled substances, the physician assistant must have obtained his or her own controlled substance license and DEA registration. The physician assistant may not use his or her supervising physicians’ controlled substance licenses or DEA registrations.
______________________________________________________________________________
PROCEDURES ADDRESSING SITUATIONS OUTSIDE THE PHYSICIAN ASSISTANT’S SCOPE OF PRACTICE:
PROCEDURES FOR PROVIDING BACKUP FOR THE PHYSICIAN ASSISTANT IN EMERGENCY SITUATIONS:
ADDITIONAL CONSIDERATIONS RELATING TO OUR PRACTICE:
Signature of Physician Assistant:
Date of Signature:
Signature of Supervising Physician:
Date of Signature:
Signature of Substitute Supervising Physician:
Date of Signature:
NOTE: It is “unprofessional conduct” under the Physician Assistant Practice Act to fail to maintain at the practice site(s) a “Delegation of Services Agreement” that accurately reflects current practices; or to fail to make the “Delegation of Services Agreement” available to DOPL for review upon request.