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Collaborative Agreement Sample A
The undersigned nurse practitioner and physician agree to the
following collaborative practice agreement for provision of health care
services to clients at (location, address)
[1.A] 2.
The health care services provided by the nurse practitioner will
include: health maintenance, management of acute episodic illness and
stable chronic illness.
[1.B] 3.
(Doctor) and (nurse practitioner )__ agree that the latest edition of
(resource) and others will be the reference texts to define referral and
consultation criteria.
As collaborating physician, (doctor) agrees to:
a) Be available for record review and co-signature (when appropriate) on
(scheduled time).
b) Be available for telephone consultation on a 24-hour basis.
c) Be on-site for consultation on (schedule time).
d) Delegate prescriptive privileges via mutually developed formulary.
As collaborating nurse practitioner, (nurse practitioner), agrees to:
a) Utilize mutually developed practice protocols.
b) Prescribe, as delegated, from the formulary, and consult, when
needed, for those medications not approved in the formulary.
c) Maintain accurate records of all consultations.
(Doctor) and (nurse practitioner) agree to review all resource/referral
guidelines, protocols and practice goals and objectives.
(Doctor and Nurse practitioner, as parties to the collaborative
agreement, are responsible and accountable for performing in accord with
the collaborative practice agreement, and within their separate and
distinct scope of practice as defined by the Michigan Public Health Code.
Agreed to by_____________________________________
(Nurse practitioner)
Approval date____________________ Review date_________________
Review date ____________________ Review date_________________
Michigan Nurses Association – January 2003