Get What Is Supervising Physician Certification 412601

Filling out the What Is Supervising Physician Certification 412601 online is a straightforward process designed to ensure that supervising physicians provide necessary information for certification. This guide will walk you through each step, ensuring that you complete the form accurately and efficiently.

Follow the steps to complete the form online

1. Click the ‘Get Form’ button to access the certification form and open it in the editor.
2. Enter the physician's name in the designated field. Ensure that the name matches the official documentation.
3. Input the physician's license number. This number is crucial for verifying the physician's credentials.
4. Provide the Physician National Provider Identifier (NPI) and the Physician Provider number in the required fields.
5. Fill in the physician's telephone number for contact purposes.
6. Complete the physician's current service address. Include all relevant details across the required lines.
7. Detail the salary arrangements you have with your Physician Assistant in the provided section. If the Physician Assistant is salaried by a Physician/Physician Group, attach a signed contract. If salaried by a Hospital/Facility, include a letter from the Chief Financial Officer explaining the salary relationship.
8. Indicate whether the Physician Assistant will practice at the same location(s) as you do by checking 'Yes' or 'No.' If 'No' is selected, list the locations where the Physician Assistant will be practicing.
9. Detail how supervision will be carried out in the section provided, including all relevant practices and procedures.
10. In the certification statement section, confirm your agreement to supervise the Physician Assistant. Fill in their NPI and Medicaid Provider number, and provide your signature, printed name, and the date.
11. Review the completed form for accuracy, then save any changes. You can also opt to download, print, or share the form as needed.

Complete the What Is Supervising Physician Certification 412601 online today to ensure compliance and proper documentation.