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  • Supervising Physician Statement Of Responsibility Form

Get Supervising Physician Statement Of Responsibility Form

New Mexico Medical Board 2055 South Pacheco Street, Bldg, 400 Santa Fe, NM 87505 (505) 476-7220 voice (505) 476-7233 fax New Applicant Replacing Previous Employer Change of Supervising Physician Adding.

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How to fill out the Supervising Physician Statement Of Responsibility Form online

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.

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Notification should be completed by using the Supervision Data Form, Form DH-MQA 2004, which is available on the web page at .FLBoardofMedicine.gov , under the Resources tab. Florida law requires specific information be provided when notifying the Board about changes in employment and/or supervising physicians.

(s) A supervising physician may not supervise at any one time more than three full-time physician assistants or their equivalent, except that a physician may supervise up to four hospital-employed physician assistants.

California physicians may practice with up to four PAs at one time. This limitation is not uncommon, as there are only 12 states that do not limit the amount of PAs with which a physician may practice.

Number of Nurse Practitioners That May Be Supervised by One Physician: Under California Business and Professions Code section 2836.1(e), a physician may supervise up to four (4) nurse practitioners (NPs) that furnish drugs or devices. There are no other limits on the number of NPs that a physician may supervise.

Physician Assistants' practice is centered on patient care and may include educational, research and administrative activities. PAs may prescribe legend medications only. The medication must be within a special formulary and must be authorized by the supervising MD or DO.

A supervising physician may be the primary supervising physician for six PAs but can be an alternate for an unlimited number of PAs.

The law limits a physician to supervise no more than four PA's, except as provided in Business and Professions Code (BPC) section 3502.5.

Generally, California is more restrictive for PAs than other states. The state dictates the majority of scope requirements, which does not allow the PA to practice independently.

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Fill Supervising Physician Statement Of Responsibility Form

I further affirm that the information in this statement of responsibility is complete and accurate to the best of my knowledge. Can I have more than one Supervising Physician? It includes sections for personal information, supervision details, alternate supervisors, and payment information for application fees. I am the responsible supervising physician for the above named physician assistant. 3.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232