Get Supervising Physician Statement Of Responsibility Form

Filling out the Supervising Physician Statement Of Responsibility Form online can streamline the process of documenting responsibilities associated with supervision. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor for online completion.
2. Begin with the section designated for the physician assistant. Enter the full name (last, first, middle initial, and maiden name), along with the state and zip/postal code. Fill out the home address, office telephone number, fax number, home telephone number, and email address.
3. Provide the physician assistant's signature and include their New Mexico license number.
4. Next, move to the section that must be completed by the supervising physician. Print or type the supervising physician's name, New Mexico license number, field of practice, business name, business address, city, business telephone number, state, zip/postal code, and fax number.
5. Specify the supervision beginning date and, if known, the supervision ending date. Remember that the ending date must be approved by the board.
6. If payment of the $25 fee is required, attach the credit card payment information page, ensuring to indicate the total amount charged to the credit card and the cardholder's name and signature.
7. If applicable, provide the names, license numbers, fields of practice, and signatures of any alternate supervising physicians. Duplicate this section as needed for additional alternates.
8. The supervising physician must certify their responsibility by signing the document and including the date of signature.
9. Review all entered information for accuracy before finalizing.
10. Once the form is complete, you can save changes, download, print, or share the completed form.

Ensure your responsibilities are documented correctly by completing your form online today.