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PAFORM 6 OKLAHOMA STATE BOARD OF MEDICAL LICENSURE AND SUPERVISION PO BOX 18256 OKLAHOMA CITY OK 73154 405 962-1400 ALTERNATE SUPERVISING PHYSICIAN EACH ALTERNATE SUPERVISING PHYSICIAN MUST COMPLETE AND SIGN ONE OF THESE FORMS. YOU MAY DUPLICATE THIS FORM AS NECESSARY. THE ALTERNATE SUPERVISING PHYSICIAN S SPECIALTY AND SCOPE OF PRACTICE MUST BE THE SAME AS OR REASONABLY SIMILAR TO THE PRIMARY SUPERVISING PHYSICIAN S SPECIALTY AND SCOPE OF PRACTICE* IF NO ALTERNATE SUPERVISING PHYSICIAN IS DESIGNATED THE PHYSICIAN ASSISTANT AND SUPERVISING PHYSICIAN MUST SIGN THE STATEMENT AT THE BOTTOM OF THIS PAGE* Date mm/dd/yy I License of Name of Alternate Supervising Physician City State AGREE TO PROVIDE ALTERNATE SUPERVISION FOR Name of Physician Assistant PA Lic* IN THE ABSENCE OF Name of Primary Supervising Physician License. I certify that my specialty is and that my scope of practice is the same as or reasonably similar to the primary supervising physician s scope of practice. Signature of Alternate Supervising Physician Signature of Primary Supervising Physician Signature of Physician Assistant SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF. SEAL MY COMMISSION EXPIRES mm/dd/yy Notary Public COMMISION NUMBER WILL NOT PRACTICE IN THE ABSENCE OF NOR INDEPENDENTLY OF THE PRIMARY SUPERVISING PHYSICIAN*. THE ALTERNATE SUPERVISING PHYSICIAN S SPECIALTY AND SCOPE OF PRACTICE MUST BE THE SAME AS OR REASONABLY SIMILAR TO THE PRIMARY SUPERVISING PHYSICIAN S SPECIALTY AND SCOPE OF PRACTICE* IF NO ALTERNATE SUPERVISING PHYSICIAN IS DESIGNATED THE PHYSICIAN ASSISTANT AND SUPERVISING PHYSICIAN MUST SIGN THE STATEMENT AT THE BOTTOM OF THIS PAGE* Date mm/dd/yy I License of Name of Alternate Supervising Physician City State AGREE TO PROVIDE ALTERNATE SUPERVISION FOR Name of Physician Assistant PA Lic* IN THE ABSENCE OF Name of Primary Supervising Physician License. I certify that my specialty is and that my scope of practice is the same as or reasonably similar to the primary supervising physician s scope of practice. I certify that my specialty is and that my scope of practice is the same as or reasonably similar to the primary supervising physician s scope of practice. Signature of Alternate Supervising Physician Signature of Primary Supervising Physician Signature of Physician Assistant SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF. Signature of Alternate Supervising Physician Signature of Primary Supervising Physician Signature of Physician Assistant SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF. SEAL MY COMMISSION EXPIRES mm/dd/yy Notary Public COMMISION NUMBER WILL NOT PRACTICE IN THE ABSENCE OF NOR INDEPENDENTLY OF THE PRIMARY SUPERVISING PHYSICIAN*. THE ALTERNATE SUPERVISING PHYSICIAN S SPECIALTY AND SCOPE OF PRACTICE MUST BE THE SAME AS OR REASONABLY SIMILAR TO THE PRIMARY SUPERVISING PHYSICIAN S SPECIALTY AND SCOPE OF PRACTICE* IF NO ALTERNATE SUPERVISING PHYSICIAN IS DESIGNATED THE PHYSICIAN ASSISTANT AND SUPERVISING PHYSICIAN MUST SIGN THE STATEMENT AT THE BOTTOM OF THIS PAGE* Date mm/dd/yy I License of Name of Alternate Supervising Physician City State AGREE TO PROVIDE ALTERNATE SUPERVISION FOR Name of Physician Assistant PA Lic* IN THE ABSENCE OF Name of Primary Supervising Physician License. I certify that my specialty is and that my scope of practice is the same as or reasonably similar to the primary supervising physician s scope of practice. Signature of Alternate Supervising Physician Signature of Primary Supervising Physician Signature of Physician Assistant SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF.