Delegation Of Service Agreement Form – Fill Out and Use This PDF

Delegation Of Service Agreement Form PDF Details

A Delegation of Services Agreement is a legally required document that authorizes a physician assistant to provide specified clinical services under the supervision of a licensed physician. Most state medical boards require this document to be signed, available at each practice site, and renewed at least once per year.

The agreement must include the following details:

• Full legal names and license numbers of the supervising physician and the physician assistant
• All authorized practice locations, including any satellite or temporary sites
• The specific clinical services the PA is authorized to perform
• Supervision type and frequency (on-site, electronic, or telephonic)
• Chart review schedule and quality oversight requirements
• Methods for immediate physician consultation in urgent situations
• Prescribing authority, including any controlled substance protocols
• Procedures for situations that fall outside the PA's authorized scope
• Emergency backup plans and alternate supervisor contact information

The agreement must be available at each practice site and submitted to the state Division of Occupational and Professional Licensing upon request. States including California, Utah, and Texas require this document to be updated at least once per year, with updated signatures from both parties. Practicing without a valid, current agreement can result in license suspension or fines for both the PA and the supervising physician.