Get Physician Assistant Active Practice Request Form And Written - Ksbha

Filling out the Physician Assistant Active Practice Request Form and Written Agreement is an essential step for Physician Assistants to practice legally in Kansas. This guide provides user-friendly, step-by-step instructions tailored for individuals at all knowledge levels to ensure a smooth completion of the form online.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the Physician Assistant Active Practice Request Form and begin the process of filling it out.
2. Section I requires you to provide personal details including your name, Kansas license number, license designation (active or exempt), and any DEA number if applicable. Make sure this information is complete and accurate.
3. In Section II, input details for the Kansas supervising physician, including their name, Kansas license number, and DEA number if applicable. Confirm whether they practice in Kansas and describe how you both will communicate when not on-site.
4. If applicable, complete Section III by detailing information for substitute supervising physicians. Include their name, Kansas license number, and confirm their engagement in practice in Kansas.
5. Moving to Section IV, provide detailed information for each practice location. Include practice name, address, phone number, type of setting, and if it is a locum tenens practice.
6. Outline the scope of practice, prescription authority, and procedures to be followed in case of patient emergencies at the practice location. Be clear about any delegations and supervision specifics.
7. Complete the attestations and signature section by ensuring all required signatories (supervising physician, physician assistant, substitute supervisors) sign and date the form properly.
8. Finally, review all sections for completeness, save any changes made, and download or print the finalized form for submission. Options for submitting include mailing to KSBHA or faxing.

Begin filling out your Physician Assistant Active Practice Request Form and Written Agreement online today to ensure compliance and maintain your practice!