Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the full legal name of the physician assistant in the designated fields for first, middle, and last names.
3. Provide the address of the physician assistant, including the street address, apartment or unit number (if applicable), city, state, and ZIP code.
4. Enter the phone number and email address in the respective fields to ensure effective communication.
5. Fill in the supervisor information section with the name of the establishment, the supervisor's name, and their license number.
6. Include the substitute supervisor's name and license number if applicable, as well as the establishment's address and telephone number.
7. Describe the degree and means of supervision, including how the supervising physician will provide oversight and what processes will be in place during times of absence.
8. Define the method for quality review by the supervising physician to ensure consistent standards are maintained.
9. If applicable, outline the process for the physician assistant to prescribe controlled substances, including obtaining a current Utah controlled substance license.
10. Specify procedures for handling situations that are outside the physician assistant’s scope of practice.
11. List the emergency procedures that will provide backup support for the physician assistant when necessary.
12. After completing all sections, ensure to have both the physician assistant and supervisor sign the form, followed by dating it.
13. Finally, save your changes, download, print, or share the completed form as required.

Start filling out the UT DoC F-70aPA-D1 online to establish your Delegation of Services Agreement today.