Form 08 4226D – Fill Out and Use This PDF

* * INCOMPLETE PLANS WILL BE RETURNED AND NOT PROCESSED **

PHYSICIAN ASSISTANT:_______________________________

PHYSICIAN:_______________________________________

Complete only for Physician Assistant practice in remote sites.

REMOTE SITE: Location of physician assistant’s practice is more than 30 miles by road from physician’s primary office.

Physician Assistants with less than two years of full-time clinical experience:

-Must work 160 hours in direct patient care under the direct and immediate supervision of the primary collaborating physician or an alternate.

-The first 40 hours must be completed before going to the remote site practice; the remaining 120 hrs must be completed

within 90 days of going to the remote site practice.

____ Hours of supervision will commence as soon as this plan is approved and prior to practicing at the remote site. The

completed Verification of Hours of Supervision form will be sent to the State Medical Board immediately upon completion of the required hours. [Physician: Initial this statement if applicable.]

- OR -

Physician assistants with more than two years of full-time clinical experience:

-Must attach a detailed curriculum vitae which describes the education, skills, and experience sufficient to meet the needs and demands of the remote site practice.

Upon my careful review, as primary collaborating physician, it is my opinion that the previous experience of the physician assistant documented in the attached curriculum vitae has adequately prepared and qualified this individual to work at the remote site practice location identified in this plan.

Primary Collaborating Physician Signature _______________________________________________________________

IMPORTANT REGULATIONS (See Booklet for Complete Regulations Language)

PERFORMANCE AND ASSESSMENT OF PRACTICE, 12 AAC 40.430: It is understood by the physician and the physician assistant that a periodic method of assessment is or will be established which will include the physician’s evaluation of physician assistant’s work performance which means evaluation of medical care and clinic management. Please refer to the full regulation for the frequency of assessments required. It is further understood that documentation of such periodic assessments may be audited by the State of Alaska at any time.

COMMUNICATIONS WITH SENSORY-IMPAIRED PATIENTS, 12 AAC 40.980(A)(4): A method is or will be devised whereby a physician assistant’s level of education and professional training are communicated to patients who may be blind, deaf, or otherwise impaired.

IDENTIFICATION OF PHYSICIAN ASSISTANT, 12 AAC 40.460: It is understood that the physician assistant will wear on his/her clothing a nameplate identifying them as a “Physician Assistant-Certified” and shall display a sign at the place of employment which posts current state licensure and that documents of the Physician Assistant’s education and plan of collaboration are available for inspection.

PRESCRIPTIVE AUTHORITY, 12 AAC 40.450:

Prescribing Schedules II, III, IV, and V [12 AAC 40.450(c)] The physician assistant named in this plan may, with a valid DEA registration, write a prescription for a schedule II, III, IV, or V controlled substance medication with primary collaboration physician’s approval.

Prescribing Authority May Not Exceed Physician’s Authority, 12 AAC 40.450(d): The PA’s prescriptive authority may not exceed that of the collaborating physician’s prescriptive authority.

Obtaining Controlled Substance Supplies, 12 AAC 40.450(e): The physician assistant named in this plan may use the physician assistant’s own DEA registration number to request, receive, order, or procure controlled substance supplies from a pharmaceutical distributor, warehouse, or other entity only with primary collaboration physician’s approval.

Prescribe, Order, Administer, or Dispense Non-Controlled Medications, 12 AAC 40.450(f): The physician assistant named in this plan may prescribe, order, administer, or dispense a medication that is not a controlled substance only with primary collaboration physician’s approval.

08-4226d (Rev. 10/15/14)

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ALASKA STATE MEDICAL BOARD

Physician Assistant Collaborative Plan

Physician Assistant	Primary Collaborative Physician
___________________________________________	__________________________________________
Name (Please Print)	Name (Please Print)
___________________________________________	__________________________________________
Address	Address
___________________________________________	__________________________________________
City, State, Zip	City, State, Zip
PA: Is this a change
License No. _____________ of address?: ___________	License No. ________________________________
Work Phone__________________________________	Work Phone _______________________________
Home Phone_________________________________	Email Address_______________________________
Email Address ___________________________________________
Alternate Physician #1	Alternate Physician #2
Name_______________________________________	Name_____________________________________
Address_____________________________________	Address___________________________________
_____________________________________	___________________________________
License No. ________ Wk Phone________________	License No. ________ Wk Phone_____________
Alternate	Alternate
Signature___________________________________	Signature__________________________________

(Attach addendum form 08-4226 (e) with additional alternates if needed.)

PRACTICE INFORMATION

Specific Location: ______________________________________________

Practice at any location not specified in this plan is not authorized.

EFFECTIVE DATE OF PLAN

Beginning Date of Employment): _____________________________

***Plan must be filed with the board NO LATER THAN 14 days from this date.***

PRESCRIPTIVE AUTHORITY (Doctor to check boxes for authority to be granted.)

12 AAC 40.450 (c) Prescribe, order, administer, and dispense schedules II, III, IV, and V drugs 12 AAC 40.450 (d) PA’s prescriptive authority does not exceed physician’s prescriptive authority 12 AAC 40.450 (e) May procure controlled substance supplies

12 AAC 40.450 (f) Prescribe, order, dispense, administer non-controlled drugs I do not wish to have any prescriptive authority under this plan.

Requirements of Law The physician assistant will work only within the agreed scope of practice with the primary physician. All parties to this plan agree to comply with the provisions of all statutes and regulations relating to the physician assistant’s practice of medicine in Alaska.

___________________________________________		_______________________________________________
Signature, Physician Assistant	Date	Signature, Primary Collaborating Physician	Date
NOTARY		NOTARY
SUBSCRIBED AND SWORN before me, a Notary Public in and for		SUBSCRIBED AND SWORN before me, a Notary Public in and for
the state of Alaska, this ______ day of ____________________, __________.		the state of Alaska, this ______ day of _____________________, __________.
______________________________________________________________		_______________________________________________________________
Notary Public		Notary Public
My commission expires___________________________________________		My commission expires____________________________________________
	(Notary Seal)		(Notary Seal)

* * Incomplete Plans Will Be Returned and Not Processed * *

08-4226d (Rev. 10/15/14)

Collaborative Plan

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ADDENDUM TO COLLABORATIVE PLAN

________________________________________________	_____________________________________________
Physician Assistant	Primary Collaborating Physician

Instructions: Print or type. If you have more than two alternate collaborating physicians for a collaborative plan, use this form to add additional alternate collaborating physicians and attach to the plan between the PA-C and the physician shown above.

ALTERNATE COLLABORATING PHYSICIAN’S STATEMENT

I hereby certify that I am familiar with the statutes and regulations of the State of Alaska governing the activities and responsibilities of a collaborating physician and that I will fulfill those responsibilities in this collaborative agreement in the absence of the primary collaborating physician. In entering into this agreement as alternate collaborating physician, I accept professional or employer liability to patients of the physician assistant for whom malpractice is adjudged. I have retained a copy of this agreement for my records. I will also maintain and make available for audit by the State of Alaska any performance assessment records which are generated as a result of this collaborative agreement in my capacity as alternate collaborating physician.

Signature					Date
Printed Name					AK License No.
Address		City	State	Zip	Telephone
3	Add	Delete	No Change
Signature					Date
Printed Name					AK License No.
Address		City	State	Zip	Telephone
4	Add	Delete	No Change
Signature					Date
Printed Name					AK License No.
Address		City	State	Zip	Telephone
08-4226e	(Rev. 10/15/14)