Supervision Data Form PDF Details

In the dynamic and regulated sphere of healthcare, the Supervision Data Form emerges as a vital document especially designed for physician assistants operating within the boundaries of Florida. This mandatory form, which needs to be updated promptly in the event of employment changes or modifications in supervisory channels, acts as a formal declaration to the Department, specifically under the stringent requirements laid out in sections s. 458.347(7)(e) and s. 459.022(7)(d), F.S. It essentially functions as a bridge between physician assistants and the governing bodies, ensuring that each assistant’s practice is under the appropriate supervision, thus upholding the high standards of healthcare provision. The form demands detailed information including but not limited to the physician assistant's license number, current mailing address, practice locations, and the credentials of supervising physicians. Not only does it facilitate a structured mechanism for adding or deleting supervisory physicians, but it also extends to the adjustment of practice locations. An inherent feature of the form is its requirement for the physician assistant's signature, underscoring the gravity and personal accountability associated with these submissions. With an aim to streamline communications and maintain up-to-date records, the process encapsulated within the DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, underscores a comprehensive strategy to regulate and monitor the evolving professional landscapes physician assistants navigate.

QuestionAnswer
Form NameSupervision Data Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesflorida supervision, alabama complaint for divorce, florida mqa supervision form, florida physician assistant supervision form

Form Preview Example

Make additional copies of page 1 as needed.

SUPERVISION DATA FORM

IMPORTANT: THIS FORM MUST BE UPDATED BY THE PHYSICIAN

ASSISTANT AS A CONDITION OF PRACTICE

Pursuant to s. 458.347(7)(e) and s. 459.022(7)(d), F.S., upon employment, a licensed physician assistant must notify the

department in writing within 30 days after such employment and after any subsequent changes in supervision.

Council on Physician Assistants, 4052 Bald Cypress Way, Bin #C-03, Tallahassee, Florida 32399-3253

***** PLEASE PRINT *****

Name:

FirstMiddle InitialLast

Florida Physician Assistant license number: PA_____________________________________________________

Print your current mailing address:________________________________________________________________

All current practice locations:

(1) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(2) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(3) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(4) Facility name: _____________________________________________________________________________

Address #:

Street:

City:

State:

Zip Code:

Return all 5 pages. This Supervision Data Form will not

be processed without the Physician Assistant’s signature and date.

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

1

 

I am ADDING the following supervising physician(s). PLEASE PRINT

Name and license number of supervising physician(s)

Specialty of supervising

Beginning date of

 

physician

Supervision

____________________________________________

 

 

ME or DO license number:

 

 

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

____________________________________________

ME or DO license number:

Make additional copies of page 2 as needed

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

2

 

I am DELETING the following supervising physician(s). PLEASE PRINT

Name and license number of supervising physician(s)

Effective date of deletion

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

 

 

___________________________________________________

 

ME or DO license number:

 

Make additional copies of page 3 as needed

 

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

3

 

I am ADDING the following practice location(s). PLEASE PRINT

(1) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(2) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(3) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(4) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(5) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(6) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(7) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(8) Facility name: _____________________________________________________________________________

Address #:

Street:

City:

State:

Zip Code:

Make additional copies of page 4 as needed

 

 

 

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

4

 

I am DELETING the following practice location(s). PLEASE PRINT

(1) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(2) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(3) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(4) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(5) Facility name: _____________________________________________________________________________

Address #:Street:City:State: Zip Code:

(6) Facility name: _____________________________________________________________________________

Address #:

Street:

City:

State:

Zip Code:

Signature of Physician Assistant

Date of signature:

Return all 5 pages. This Supervision Data Form will not be processed without the Physician Assistant’s signature and date.

DH-MQA 2004, Rules 64B8-30.003 and 64B15-6.003, Revised 08/10

5

 

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