Get Delegation Of Services Agreement

Filling out the Delegation of Services Agreement is an essential task for physician assistants and their supervising physicians. This guide provides step-by-step instructions to complete the form accurately and efficiently online.

Follow the steps to successfully complete the Delegation of Services Agreement online.

1. Click ‘Get Form’ button to obtain the Delegation of Services Agreement and access it in your preferred online editing platform.
2. Start by entering the physician assistant's name in the designated field. Ensure that all information is legible and accurate.
3. Next, fill in the supervising physician's name and their Utah license number. This identification is crucial for establishing the supervisory relationship.
4. List any substitute supervising physicians. For each substitute, provide their name and Utah license number in the given fields. If there are more than four substitutes, you may use additional sheets.
5. Document the practice site(s) where the services will be provided. For each facility, include the name, address, city, state, and zip code.
6. In the degree and means of supervision section, describe how the supervising physician will provide oversight. Include methods for immediate electronic consultation as required when direct supervision is not possible.
7. Specify the frequency and mechanism of chart reviews to ensure ongoing compliance and support for the physician assistant’s practice.
8. If applicable, indicate the conditions under which the physician assistant may prescribe controlled substances, including details about obtaining the necessary licenses and registrations.
9. Outline procedures addressing situations outside the physician assistant's scope of practice. Ensure clarity for any emergencies that may arise.
10. After completing the form, the physician assistant, supervising physician, and any substitute supervising physicians must sign and date the agreement.
11. Once all sections are filled out and signed, review the document for accuracy. You can then save changes, download, print, or share the form as needed.

Complete your Delegation of Services Agreement online today to ensure compliance and effective practice.