Get Verification Of Supervision/employment Supervising Physician's ... - Nj

Filling out the Verification of Supervision/Employment Supervising Physician's form is an essential step in ensuring that Physician Assistants practice under appropriate supervision. This guide provides you with a clear, step-by-step approach to completing the form accurately and efficiently online.

Follow the steps to complete your form seamlessly.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Enter the current date in the designated field. This is the date when the supervising arrangement is effective.
3. Provide the full name of the Physician Assistant in the appropriate field. Ensure the spelling is correct for verification purposes.
4. Indicate the supervising physician's name by filling out the corresponding section. Make sure to print the name clearly to avoid any confusion.
5. Specify the field of practice for the Physician Assistant. This information is critical in defining the scope of practice.
6. Select the type of facility—either inpatient or outpatient—by circling the correct option.
7. Fill in the name of the practice or facility where the Physician Assistant will be working.
8. Insert the New Jersey Physician License Number of the supervising physician in the given field.
9. Provide the telephone number, including the area code, for easy contact.
10. Complete the street address, city, state, and ZIP code of the practice facility.
11. If the employer differs from the practice facility, fill in the employer's information in the provided fields, including street address, city, state, and ZIP code.
12. Acknowledge that a plenary licensed Physician Designee will provide supervision in your absence.
13. Read the Supervising Physician's Affidavit section carefully and ensure all statements are true before signing.
14. Print the names of the supervising physician, employer, and Physician Assistant as required.
15. Ensure all signatures are added in the designated spaces, along with the respective dates.
16. Once all information is complete, save changes, and download or print the form as needed.

Complete your Verification of Supervision/Employment Supervising Physician's form online today for a smooth approval process.