Last updated on May 31, 2018 by System Legal Affairs

Collaborative Practice Agreement

Instructions Sheet

Outlined in this document the instructions for completing the “Collaborative Practice Agreement” and forming

an collaborative practice agreement between a Physician and Advanced Practice Nurse in the state of Missouri. For

further questions regarding the form that are not answered in here please contact SSM Health System Legal Affairs.

1. Page 1: Using the Collaborative Practice Agreement form, fill in all fields appropriately. The effective date is the date

the collaboration is to commence between the Physician and APN.

2. Page 2, 3, 4, and 5: Controlled Substance Authority - Under Section 1.2(a), check the box best describing the

Physician’s desire to delegate controlled substance authority to the APN.

a. Section 1.2(a)(i) – by checking “Applies” here, the Physician is prohibiting the APN from prescribing controlled

substances under the Agreement.

i. When controlled substance authority is not granted – check both “Does not apply” is in Section 1.2(a)(ii) and

“Not Authorized” at the end of Section 1.3.

b. Section 1.2(a)(ii) – by checking “Applies” here, the Physician is delegating controlled substance authority to the

APN subject to additional considerations in the agreement..

i. If controlled substance authority is granted by Section 1.2(a)(ii), indicate any restrictions of scheduled classes

in Section 1.3.1 and check “Applies” at the end of Section 1.3

ii. Furthermore, be sure to have the Physician review and indicate which controlled substances are delegated by

attaching, and retaining with this Agreement, the SCHEDULE - Controlled Substances MO found in the

documents folder.

4. Page 12: Signatures Page – Complete all fields as they are required and outlined. The SSM Health Representative is

the applicable Hospital Chief Nursing Officer or SSM Health Medical Group Administrative Director for Nursing

Operations that oversees the applicable entity’s nursing operations.

5. Page 13: Exhibit 1, Protocols – Insert, using multiple pages if needed, the appropriate, pre-approved protocols that are

to be delegated to the APN. These protocols can be found on the SSM Health System Legal Affairs intranet page and

should take into account both professionals skills and experience. This section should also mirror privileges granted to

APN under the applicable SSM Health Privileges Form, and if any clinical privileges are granted to APN at SSM Health

hospitals, it should be documented here.

6. Page 15: Exhibit 2, Designated Physicians - In the absence of, or in the event the Collaborating Physician is not

immediately available to the APN for consultation, a back-up or Designated or Physician must fulfill the responsibility

of collaboration. Indicate all Designated Physician’s information in the appropriate row and have said Designated

Physician acknowledge their responsibilities on the following page via signature.

7. Page 17: Exhibit 3, Practice Locations – Indicate the address of all locations where an APN has been delegated

authority to collaboratively practice by the Physician. Remember these practice locations must be consistent with any

delegation of Clinical Privileges at SSM Health hospitals.

8. Page 19: Exhibit 5, Written Practice Agreements – In the appropriate box, list all other CPA’s that the Physician and

APN have entered into. Remember a Physician may not supervise more than six (6) FTE APNs.

9. After the form is fully completed, obtain all necessary signatures and provide a copy to the nursing manager and

applicable Hospital Chief Nursing Officer or SSM Health Medical Group Administrative Director for Nursing

Operations that oversees the applicable entity’s nursing operations. Be sure the Physician and APN

maintains the completed agreement for a minimum of eight (8) years and that such agreement is readily available for

any agency inspection.

Page 5: Delegation of Restraint Authority - Check the appropriate boxes in Section 1.5 for level of restraint authority delegated by Physician to the APN.

3.

Version:5/18/2018

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COLLABORATIVE PRACTICE AGREEMENT

The following terms defined below shall be applicable to this Agreement:

This COLLABORATIVE PRACTICE AGREEMENT (“Agreement”) shall be effective on EFFECTIVE DATE by and between PHYSICIAN and APN.

WHEREAS, PHYSICIAN is licensed in Missouri and employed by PHYSICIAN EMPLOYER to provide PHYSICIAN SPECIALTY medical services, and APN is licensed in Missouri as an advanced practice nurse certified by APN BOARD CERTIFICATION and employed by APN EMPLOYER to provide professional nursing services in accordance with APN’s applicable job description and as authorized by Missouri law; and

WHEREAS, in order to facilitate the provision of professional services in a collaborative fashion between PHYSICIAN and APN, PHYSICIAN desires to delegate certain medical acts to APN for services rendered at designated PRACTICE SITES in a manner consistent with APN’s skill, training, competence and professional judgment and Missouri collaborative practice law.

THEREFORE, for and in consideration of the covenants and promises herein provided, PHYSICIAN and APN agree as follows:

1. Delegation of Authority. PHYSICIAN has considered APN’s skill, training, education andcompetence and has determined that the responsibilities delegated herein are within the scope ofpractice of the APN and are consistent with APN’s skill, training, education and competence; andthe methods of treatment and the authority to administer, dispense and prescribe the drugs and

EFFECTIVE DATE:

PHYSICIAN:

PHYSICIAN EMPLOYER:

PHYSICIAN SPECIALTY:

ADVANCED PRACTICE NURSE (APN):

APN EMPLOYER:

APN BOARD CERTIFICATION:

PRACTICE SITE or HOSPITAL:

Shall include all sites, listed by Exhibit 3 and hereby incorporated into this Agreement, where APN is authorized by PHYSICIAN to collaboratively practice under the terms of this agreement.

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medications delegated to APN herein are consistent with PHYSICIAN’s and APN’s skill, training, education and competence and within the scope of practice of PHYSICIAN and APN.

1.1 Clinical Privileges at SSM Health Hospitals. PHYSICIAN and APN understand that SSM Health will only grant privileges

specified in the Clinical Privileges form, as amended and maintained by SSM Health. Any privileges specified in Exhibit 1 that exceed the scope of those privileges granted by SSM Health are not permitted under this Agreement.

1.2 Delegation of Prescriptive Authority: PHYSICIAN hereby delegates to APN the authority to administer, dispense and

prescribe drugs pursuant to this Agreement and to provide treatment within APN’s scope of practice, consistent with APN’s skills, training, education and competence, in accordance with Exhibit 1, “Scope of Practice,” which is attached hereto and incorporated herein by reference. Exhibit 1 may be revised by PHYSICIAN and APN from time to time. The authority to administer, dispense and prescribe drugs as delegated to APN pursuant to the conditions set forth in the section and subsections of this Agreement is subject to the following conditions:

(a) Controlled Substance Prescriptive Authority:

i. APN shall not, under any circumstances, prescribe controlled substances. Theadministering or dispensing of controlled substances by APN under thisAgreement shall be accomplished only under the direction and supervision ofPHYSICIAN, or one of the Designated Physicians, and shall only occur on acase-by-case determination of the patient’s needs following verbalconsultation between PHYSICIAN and APN. The required consultation andPHYSICIAN’s (or, if applicable, Designated Physicians') directions for theadministering or dispensing of controlled substances shall be recorded in thepatient’s chart and in the appropriate dispensing log. These recordings shallbe made by APN and shall be co-signed by PHYSICIAN (or the DesignatedPhysicians, if applicable) following a review of the records.

By marking “Applies,” PHYSICIAN hereby affirms that APRN has not beendelegated any authority to prescribe controlled substances or any othersubstance PHYSICIAN is not dually authorized to prescribe:

Section 1.2.(a)(i) Applies Does not apply

ii. APN may prescribe controlled substances pursuant to the provisions of thisAgreement. APN shall not, under any circumstances, prescribe controlledsubstances or any drug that the PHYSICIAN is not qualified or authorized toprovide. The prescribing, administering or dispensing of controlled substancesby APN under this Agreement shall be accomplished only under the directionand supervision of PHYSICIAN. The PHYSICIAN and/or authorized APN’sdirections for the prescribing, administering or dispensing of controlledsubstances shall be recorded in the patient’s chart and the appropriatedispensing log. These recordings shall be noted by APN and shall be co-signedby PHYSICIAN following review of the records.

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If APN holds a certificate of controlled substance prescriptive authority from the board of nursing under Section 335.019 R.S.Mo., APN may prescribe controlled substances listed in Schedules II (restricted to products containing hydrocodone only), III, IV, and V of Section 195.017, R.S.Mo., but not for the purpose of inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures, and not for APN or APN’s family. Schedule II hydrocodone products or Schedule III narcotic controlled substance prescriptions shall be limited to a one hundred twenty (120) hour supply without refill. The controlled substances which PHYSICIAN authorizes APN to prescribe are listed in Exhibit 1.

By marking “Applies,” PHYSICIAN hereby affirms that APN has been delegated controlled substance prescriptive authority as set forth by the terms of the entire Agreement:

Section 1.2.(a)(ii) Applies Does not apply

(b) APN may only dispense starter doses of medication to cover a period of time for seventy-two (72) hours or less.

(c) The dispensing of drug samples, as defined in 21 U.S.C. § 353(c)(1), is permitted as appropriate as allowed by the PHYSICIAN to complete drug therapy.

(d) All prescription container labeling requirements outlined in Section 338.059, R.S.Mo. shall be followed.

(e) Consumer product safety laws and Class B container standards shall be followed when packaging drugs for distribution.

(f) All drugs shall be stored according to United States Pharmacopeia (USP) recommended conditions, and outdated drugs shall be separated from active inventory.

(g) Retrievable dispensing logs shall be maintained for all prescription drugs dispensed and shall include all information required by state and federal statutes, rules or regulations.

(h) All prescriptions shall conform to all applicable state and federal statutes, rules and regulations and shall include the name, address and telephone number of PHYSICIAN and APN.

(i) There shall be posted at every office where APN is authorized to prescribe, in collaboration with PHYSICIAN, a prominently displayed disclosure statement

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informing patients that they may be seen by an advanced practice registered nurse and have the right to see the collaborating physician.

1.3 Limitations to Delegation of Controlled Substance Authority: PHYSICIAN hereby delegates to APN the authority to administer, dispense and

prescribe drugs including all controlled substances as listed in Section 195.017 R.S.Mo., with the exception of controlled substances prescribed for the purpose of inducing sedation or general anesthesia for therapeutic, diagnostic or surgical procedures (“Eligible Controlled Substances”), and to provide treatment within APN’s scope of practice, consistent with APN’s skills, training, education and competence, in accordance with Exhibit 1, which is attached hereto and incorporated herein by reference. Section 1.3 shall not apply in the event that section 1.2(a)(i), stated above, applies to this agreement.

1.3.1 Delegation of specific Schedules of Controlled Substances. If Section 1.2(a)(ii) Applies, the following schedules of controlled substances are hereby delegated, and each individual substance shall be listed in Exhibit 1:

Schedule II: Authorized Not Authorized Schedule III: Authorized Not Authorized Schedule IV: Authorized Not Authorized Schedule V: Authorized Not Authorized

1.3.2 APN shall receive and maintain a current and valid Certificate of Controlled Substance Prescriptive Authority from the Missouri Board of Nursing in accordance with 20 C.S.R. 2200-4.100;

1.3.3 APN shall receive and maintain a current and valid Missouri controlled substances registration with the Missouri Bureau of Narcotics and Dangerous Drugs (“BNDD”) pursuant to 19 C.S.R. 30-1.017;

1.3.4 APN shall receive and maintain a current and valid Drug Enforcement Agency (“DEA”) registration number; and

1.3.5 PHYSICIAN shall receive and maintain a current and valid: (a) controlled substances registration with the BNDD; and (b) DEA registration number.

1.3.6 APN shall not be permitted to independently purchase or stock any controlled substances as listed in Section 195.017 R.S.Mo.

1.3.7 All Eligible Controlled Substances that APN is permitted to prescribe shall be listed on Exhibit 1.

1.3.8 APN will only prescribe Eligible Controlled Substances that are consistent with each professional’s education, knowledge, skill and competence.

1.3.9 Schedule II hydrocodone products or Schedule III narcotic controlled substances shall be limited for a 120-hour supply, without refill.

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By marking “Authorized,” PHYSICIAN hereby affirms that APN has been delegated controlled substance prescriptive authority as set forth by the terms of the entire Agreement and subject to the contingencies listed in Section 1.3: Section 1.3: Authorized Not Authorized

1.4 Notwithstanding the delegation of such medical acts, the parties recognize that APN is a registered professional nurse with additional education and training in an advanced practice nursing clinical specialty area and as such is authorized by the Nursing Practice Act to engage in professional nursing and perform independent nursing acts consistent with APN’s specialized knowledge, judgment, skill, training and education without medical supervision or delegation. This Agreement only applies to delegated medical acts and those nursing acts requiring physician orders and not to APN’s independent practice of nursing.

2. Geographic Restrictions.

PHYSICIAN and APN’s practice is located at the Practice Site(s) set forth on Exhibit 3.Notwithstanding anything to the contrary herein, at all times while this Agreement is in effect,APN and PHYSICIAN shall practice within seventy-five (75) miles by road of one another. APNshall not practice at a location where PHYSICIAN is not continuously present unless APN shallfirst practice at the same location with PHYSICIAN for a period of at least one (1) calendar monthbefore practicing at a location where PHYSICIAN is not present. PHYSICIAN shall determineand document the completion of this one month period.

3. Oversight and Review; Physician’s Obligations.

3.1 PHYSICIAN shall at all times be immediately available for consultation to APN, either personally or via telecommunications. APN and PHYSICIAN agree, and PHYSICIAN hereby designates the following physicians (“Designated Physicians”) set forth on Exhibit 2, attached hereto and incorporated herein by reference, to consult, direct or supervise APN in the event PHYSICIAN is unavailable for consultation due to temporary illness, injury or absence.

3.2 PHYSICIAN, in collaboration with APN, shall review the work records and practice of the APN at least every two (2) weeks regarding the quality and appropriateness of professional services provided pursuant to this Agreement. PHYSICIAN shall document each review and evaluation. The review process and documentation of the review process implemented by PHYSICIAN and APN shall be on file and maintained by PHYSICIAN at the Practice Site.

3.2.1 If contracting with a medical group, records to be reviewed shall include, but not be limited to, notes involving new patients, patients exhibiting a new chronic condition or significant change in a serious condition, and/or notes in which controlled substances are dispensed and APN’s prescribing practices. This may be accomplished by record review, chart audits, or discussion of patient care/management issues.

1.5 PHYSICIAN hereby delegates the following authority regarding the use of restraints:Authority to order restraints and/or seclusion for patients with violent or self-destructive behavior in a dedicated psychiatric unit:

Applies (Only allowed at SSM Health DePaul Hospital - St. Louis,SSM Health St. Joseph Hospital - St. Charles, and SSM Health St. Mary's Hospital - St. Louis)

Does NOT Apply

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3.2.2 PHYSICIAN shall complete a review of a minimum of ten percent (10%) of the total health care services delivered by APN. APN’s documentation shall be submitted for review to PHYSICIAN at least every fourteen (14) days.

3.2.3 PHYSICIAN, within fourteen (14) days, shall perform a random sample review of at least twenty percent (20%) of the charts in which the APN prescribed a controlled substance. PHYSICIAN shall document each review and evaluation. The review process and documentation of the review process implemented by PHYSICIAN and APN shall be on file and maintained by PHYSICIAN at the Practice Site. This provision shall apply if Section 1.3 applies.

3.2.4 The documentation shall at a minimum contain patient name, date of birth, date of service, diagnosis and a summary of the PHYSICIAN’s review. The review process and documentation of each review shall be maintained on file at the Practice Site and readily available for review.

3.3 PHYSICIAN and APN have determined an appropriate process for the review and management of abnormal test results in accordance with standing Practice Site policy as set forth on Exhibit 4.

3.4 When APN utilizes this Agreement to provide health care services for conditions other than acute self-limited or well-defined problems, PHYSICIAN shall see the patient for evaluation and approve or formulate the plan of treatment for any new or significantly changed conditions as soon as practical but in no case more than two weeks after the patient has been seen by APN. (This provision does not apply to an APN providing inpatient care in the traditional scope of practice as a registered nurse.)

3.5 This Agreement shall be reviewed and revised at least annually by PHYSICIAN and APN, and all such revisions shall be acknowledged by HOSPITAL and PHYSICIAN EMPLOYER.

3.6 PHYSICIAN shall, within thirty (30) days of any change and upon each renewal (each, a “Notice Event”), provide notice to the Missouri State Board of Registration for Healing Arts. Such notice shall include the identification of each collaborative practice agreement to which the PHYSICIAN is a party and the name(s) of the APN and any other licensed professional with whom the PHYSICIAN has entered into such agreement.

3.7 PHYSICIAN and APN agree to abide by the process on receiving and reporting lab results in accordance with standing Practice Site policy as set forth on Exhibit 7, “Laboratory Results Protocol.” Section 3.7 shall apply only to agreements containing clinic sites in the SSM Health Mid-Missouri region.

4. Terms and Conditions.

4.1 All services performed pursuant to this Agreement shall be performed in a manner consistent with HOSPITAL’s Medical Staff Bylaws and related Manuals and HOSPITAL’s policies and procedures.

4.2 Each party represents and warrants to the other party that it, its owners, employees, agents and any subcontractors (collectively “Personnel”) are not: (i) listed on the System

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for Award Management website (“sam.gov”) with an active exclusion; (ii) listed on the Office of the Inspector General’s website (“oig.hhs.gov”); (iii) suspended or excluded from participation in any federal health care programs as defined under 42 U.S.C. § 1320a-7b(f); or (iv) suspended or excluded from participation in any form of state Medicaid program ((i)-(iv) collectively, “Government Payor Programs”). Each party also represents and warrants to the best of its knowledge there are no pending or threatened governmental investigations that may lead to suspension or exclusion of that party or its Personnel from Government Payor Programs or may be cause for listing on sam.gov or oig.hhs.gov (collectively, an “Investigation”). Each party shall notify the other party of the commencement of any Investigation, suspension or exclusion from Government Payor Programs within three (3) business days of its first learning of it. Either party shall have the right to immediately terminate this Agreement upon learning of any such Investigation, suspension or exclusion. Each party shall be kept apprised by the other party in a timely manner of the status of any such Investigation. Each party shall indemnify, defend and hold the other party harmless from any claims, liabilities, fines and expenses (including reasonable attorneys’ fees) incurred as a result of the other party’s breach of this paragraph.

5. Term and Termination.

5.1 The term of this Agreement shall commence on the Effective Date and shall continue until terminated herein. This Agreement shall be reviewed on an annual basis by both the PHYSICIAN and APN.

5.2 This Agreement can be terminated at any time by either PHYSICIAN or APN upon written notice to the other. The terminating party shall concurrently forward a copy of the notice of termination to HOSPITAL and PHYSICIAN EMPLOYER.

5.3 In addition, this Agreement terminates automatically and immediately without written notice upon:

(a) termination of the employment relationship between APN and HOSPITAL, or between PHYSICIAN and PHYSICIAN EMPLOYER;

(b) termination of PHYSICIAN’s Medical Staff or APN’s Allied Health Professional Staff membership and/or clinical privileges at HOSPITAL;

(c) suspension, revocation, nonrenewal or other adverse action taken with respect to PHYSICIAN’s medical license, BNDD or DEA certifications;

(d) suspension, revocation, nonrenewal or other adverse action taken with respect to PHYSICIAN’s medical license or APN’s nursing license;

(e) Nonrenewal, expiration or termination of PHYSICIAN’s or APN’s professional liability insurance as required under the provisions of Section 6, below; or

(f) PHYSICIAN’s or APN’s suspension or exclusion from any federal or state health care reimbursement program as more fully set forth in Section 4.2, above.

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6. Insurance.

6.1 At all times during the term of this Agreement, PHYSICIAN and APN shall each procure and maintain an insurance policy (or self-insurance) providing medical professional liability coverage or self-insurance on an occurrence basis (or in accordance with Section 6.2 if such coverage is not on an occurrence basis, e.g., “Claims Made”) covering PHYSICIAN or APN (whichever is applicable) in the minimum amounts of One Million Dollars ($1,000,000.00) per occurrence and Three Million Dollars ($3,000,000.00) annual aggregate of all claims (“Insurance Coverage”). PHYSICIAN and APN may procure the Insurance Coverage set forth herein through their respective employers, and in the event that PHYSICIAN or APN elect to procure such Insurance Coverage through their respective employers, then the insurance obligations set forth in this Section 6 shall accrue to their respective employers.

6.2 If PHYSICIAN or APN each individually or through their respective employers procure Insurance Coverage that is not on an “occurrence basis,” then PHYSICIAN or APN (whichever is applicable) shall, at all times, including without limitation, after the expiration or termination of this Agreement for any reason, maintain Insurance Coverage for any liability directly or indirectly resulting from PHYSICIAN or APN’s provision of medical services, or acts or omissions of PHYSICIAN or PHYSICIAN’s employees and agents, or APN or APN’s employees and agents occurring in whole or in part during the term of this Agreement (“Continuing Coverage”). PHYSICIAN or APN may procure such Continuing Coverage by obtaining subsequent insurance policies that have a retroactive date of coverage on or before the Effective Date, by obtaining an extended reporting endorsement applicable to the Insurance Coverage maintained by PHYSICIAN or APN during the term of this Agreement or by such other method reasonably acceptable to the parties.

6.3 PHYSICIAN and APN shall, upon request, provide each other, with a copy to HOSPITAL and PHYSICIAN EMPLOYER, with certificates which shall state the amount of any applicable deductible, issued by the insurance policy carrier or its agent evidencing that all insurance required hereunder is in effect and require that such insurance carrier or agent shall provide PHYSICIAN and APN with at least fifteen (15) days prior written notice of any modification, cancellation or nonrenewal of such policy, with a copy to HOSPITAL and PHYSICIAN EMPLOYER. All commercial insurance shall be issued by responsible insurance carriers or through self-insurance reasonably acceptable to the parties.

6.4 The obligations of PHYSICIAN and APN under this Section 6 shall survive the expiration or termination of this Agreement for any reason.

7. Billing and Payment for Services.

HOSPITAL shall bill for all clinical services provided by APN under this Agreement on a monthly or more frequent basis, and shall retain all revenues received from such billings. PHYSICIAN EMPLOYER or PHYSICIAN shall not directly or indirectly bill any party for any services provided by APN pursuant to this Agreement, including, without limitation, Medicare beneficiaries or APN’s carrier under Part B of Medicare. PHYSICIAN EMPLOYER or PHYSICIAN shall promptly remit to HOSPITAL any amounts received in connection with, relating to, or arising from APN’s services provided pursuant to this Agreement, including but not limited to any amounts received from managed care plans (including, without limitation, any bonus payments, surplus

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distribution or withhold returns). The provisions of this Section shall survive the expiration or termination of this Agreement for any reason.

8. Miscellaneous.

8.1 Document Retention.

PHYSICIAN and APN each agree to maintain copies of this Agreement, any and all amendments, exhibits, protocols, standing orders and modifications thereto, and any notice of termination of this Agreement for a minimum of eight (8) years after termination of this Agreement.

8.2 Limitation on Collaborative Arrangements.

PHYSICIAN shall not enter into Collaborative Practice Site Arrangements with more than six (6) full-time equivalent Advanced Practice Site Nurses, including APN. A list of other written practice agreements of PHYSICIAN and APN is set forth on Exhibit 5.

Guidelines for consultation and referral to Physician or a designated health facility for services or emergency care that is beyond the education, training, competence or scope of practice of the APN are set forth in Exhibit 6.

8.3 Documentation of Quality Reviews.

The process and documentation of review of health care services described in Section 3 above shall be maintained by PHYSICIAN at the Practice Site, and shall be made available to any of the parties upon request.

8.4 Assignment and Subcontracting.

The purpose of this Agreement is to secure the services of PHYSICIAN in the performance of supervisory services of APN as more fully set forth hereunder. Accordingly, neither PHYSICIAN nor APN may assign his/her rights or obligations under this Agreement nor otherwise subcontract for, or delegate, the performance of his/her obligations under this Agreement to any other person or entity. Notwithstanding the foregoing, HOSPITAL and PHYSICIAN EMPLOYER may, without the prior consent of the other party, assign its respective rights and obligations under this Agreement to another legal entity owned or controlled by, under common control or affiliated with, HOSPITAL or PHYSICIAN EMPLOYER (whichever is applicable).

8.5 Independent Contractors.

For purposes of this Agreement, PHYSICIAN and APN are independent contractors, and this Agreement shall not constitute the formation of a partnership, joint venture, employment or master-servant relationship. The parties further agree that PHYSICIAN shall not be entitled to any benefits of an employee of HOSPITAL, nor shall PHYSICIAN be entitled to any benefits to which APN as an employee of HOSPITAL receives, because of the creation or existence of this Agreement, except as specifically provided herein. In addition, for purposes of this Agreement, PHYSICIAN EMPLOYER and HOSPITAL are independent contractors, and this Agreement shall not constitute the formation of a partnership, joint venture, employment or master-servant relationship.

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8.6 Entire Agreement.

This Agreement contains the entire understanding between the parties hereto and supersedes all prior proposals, negotiations, representations, communications, writings and agreements between the parties with respect to the subject matter hereof, whether oral or written. No amendment, change, modification or alteration of the terms and conditions hereof shall be binding unless evidenced by a subsequent writing signed by the parties hereto. This Agreement shall be binding on the parties, their successors, and permitted assigns.

8.7 Governing Law; Change in Law.

This Agreement and any disputes arising hereunder shall be governed by the substantive laws of the State of Missouri without regard to Missouri’s conflict of laws provisions. The parties agree that this Agreement is subject to all applicable state, local and federal laws and regulations, as well as the standards of The Joint Commission and any amendments thereto, during the term of this Agreement. In the event any provision in this Agreement shall be deemed, by either party, to be a violation of law or regulation, enacted after the execution of this Agreement, or to be inconsistent with the laws or regulations existing as of the date of this Agreement but interpreted by a court or regulatory authority of competent jurisdiction after the execution of this Agreement, then the parties shall proceed in good faith to renegotiate this Agreement to eliminate such violation upon written notice of such violation to the other party hereto. If an amended agreement cannot be reached by the parties within thirty (30) days from the receipt of the written notice, then this Agreement shall be subject to termination by either party upon ten (10) days written notice to the other party.

8.8 Waiver of Breach.

The failure of any party to this Agreement to object or take affirmative action with respect to any conduct of the other party which is in violation of the provisions of this Agreement shall not be construed as a waiver of that violation or of any future violations of the provisions of this Agreement.

8.9 Notice.

Any notices or other communications required or contemplated under the provisions of this Agreement shall be in writing, delivered in person, evidenced by a signed receipt or sent by certified mail, return receipt requested, postage pre-paid, to the addresses indicated below or to such other persons or addresses as the parties may provide by notice to the other. The date of notice shall be the date of delivery if personally delivered or the date of mailing if the notice is mailed by certified mail.

8.10 Confidentiality.

8.10.1 Business and Financial Information. PHYSICIAN acknowledges that during PHYSICIAN’s association with APN, PHYSICIAN will be brought into contact with HOSPITAL’s confidential methods of operations, pricing policies, marketing strategies, trade secrets, knowledge, techniques, data and other information about HOSPITAL’s operations and business of a confidential nature (“Confidential

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Information”) and that such Confidential Information has a special and unique value to HOSPITAL. Therefore, PHYSICIAN will not in any manner, directly or indirectly, disclose or divulge to any person, or other entity, whatsoever, or use for his/her own benefit or for the benefit of any other person or other entity whatsoever, directly or indirectly in competition with HOSPITAL, any of such Confidential Information. Upon the expiration or termination by any party for any reason of this Agreement, PHYSICIAN shall immediately return to HOSPITAL any and all such Confidential Information in possession or control of PHYSICIAN.

8.10.2 Patient Identifying Information. All parties to this Agreement shall comply with all applicable state and federal laws and regulations regarding confidentiality of patient records, including but not limited to the Health Insurance Portability and Accountability Act of 1996 and the Privacy and Security Standards (45 C.F.R. Parts 160 and 164) and the Standards for Electronic Transactions (45 C.F.R. Parts 160 and 162) (collectively, the “Standards”) promulgated or to be promulgated by the Secretary of Health and Human Services on and after the applicable effective dates specified in the Standards. All medical information and data concerning specific patients, including but not limited to the identity of the patients, derived from the business relationship set forth in this Agreement shall be treated and maintained in a confidential manner by all parties to this Agreement and shall not be released, disclosed, or published to any party other than as required or permitted under applicable laws. All parties shall sign any additional documents as may be required by law to comply with this provision.

8.11 Attorneys’ Fees. In the event legal action is instituted to enforce this Agreement or any part hereof, the prevailing party shall be entitled to reasonable attorneys’ fees and actual costs incurred in connection with such action.

8.12 Affirmative Action Statement. Hospital and all covered subcontractors shall abide by the requirements of 29 CFR Part 471, Appendix A to Subpart A, 41 CFR § 60-1.4(a), 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin. Moreover, these regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability.

8.13 Counterparts, Facsimile, or Electronic Signature.

This Agreement may be signed in one or more counterparts including via facsimile or email, or by electronic signature in accordance with Missouri law, all of which shall be considered one and the same agreement, binding on all parties hereto, notwithstanding that both parties are not signatories to the same counterpart. A signed facsimile or photocopy of this Agreement shall be binding on the parties to this Agreement.

8.14 Incorporated by Reference. All exhibits referenced in this Agreement shall be attached hereto and incorporated herein to this Agreement.

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IN WITNESS WHEREOF, each person signing below represents and warrants that he or she is fully authorized to sign and deliver this Agreement in the capacity set forth beneath his or her signature and the parties hereto have signed this Agreement as of the date and year written below.

PHYSICIAN:

By:____________________________________

Date: __________________________________

Home Address:

Home No.:

Work Address:

Work No.:

Pager No.:

Cell No.:

Email:

APN:

By:____________________________________

Date: __________________________________

Home Address:

Home No.:

Work Address:

Work No.:

Pager No.:

Cell No.:

Email:

ACKNOWLEDGED BY SSM HEALTH REPRESENTATIVE:

By:____________________________________

Date: __________________________________

Title:

Email:

Physician / Date:_________ APN / Date:_________

Physician / Date:_________ APN / Date:_________

Physician / Date:_________ APN / Date:_________

Physician / Date:_________ APN / Date:_________

Physician / Date:_________ APN / Date:_________

ANNUAL REVIEW (Please initial and date):

Name: Name:

Page 13 of 21

EXHIBIT 1

REFERENCES, GUIDELINES, PROTOCOLS, PRIVILEGES AND STANDING ORDERS

APN and PHYSICIAN shall participate in the joint formulation and joint approval of orders or guidelines with the APN and periodically review such orders and the services provided patients under such orders in accordance with accepted standards of medical practice and advanced practice nursing practice. Any delegation of privileges granted to APN at SSM Health hospitals shall align with the clinical privileges granted to APN under the applicable SSM Health Clinical Privilege Form.

Page 14 of 21

EXHIBIT 1 (continued)

REFERENCES, GUIDELINES, PROTOCOLS, PRIVILEGES AND STANDING ORDERS

EXHIBIT 2

DESIGNATED PHYSICIANS Physician Name Work No. Pager No. Cell No. Home No. Work Address Home Address

Page 15 of 21

EXHIBIT 2 (continued)

ACKNOWLEDGEMENT OF DESIGNATED PHYSICIANS

I, the undersigned physician, acknowledge and agree that I am a Designated Physician under the terms and conditions stated in this Agreement, and that I have received and read a copy of such Agreement and understand its contents as applicable to me.

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Name Date Name Date

Name Date Name Date

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Name Date Name Date

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Name Date Name Date

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Page 16 of 21

Page 17 of 21

EXHIBIT 3

PRACTICE LOCATIONS

Please enter office/hospital name and full address:

Page 18 of 21

EXHIBIT 4

ABNORMAL TEST RESULTS

Documentation process for review and management of abnormal test results shall be as follows:

1. APN shall review all test results as soon as they are available.

2. Abnormal results that are deemed by APN to require consultation with a PHYSICIAN orDesignated Physician shall be discussed or forwarded to the PHYSICIAN or Designated Physicianto determine an appropriate course of treatment.

3. PHYSICIAN or Designated Physician with whom abnormal results are reviewed will sign off onthese results once reviewed.

4. APN will document, in the patient’s medical record, the actions that were taken upon review of theabnormal test results described in this Exhibit 4, Section 2 above. The APN will sign, date, andtime this documentation.

Page 19 of 21

EXHIBIT 5

WRITTEN PRACTICE AGREEMENTS

Physician Collaborative Practice Agreements:List all other CPA agreements with other APNs

APN Collaborative Practice Agreements: List all Collaborative Practice Agreements APN has with other Physicians

Page 20 of 21

EXHIBIT 6

GUIDELINES FOR CONSULTATION AND REFERRAL

In the event that, in the APN’s professional judgment, a patient under the APN’s treatment requires consultation, referral or emergency care, which is beyond the APN’s education, training, competence or scope of practice, APN may consult with PHYSICIAN within a medically appropriate time frame. In emergency situations, the APN may consult with PHYSICIAN, Designated Physician(s), or any PHYSICIAN with the appropriate specialty.

Page 21 of 21

EXHIBIT 7

LABORATORY RESULTS-RECEIPT AND FOLLOW-UP POLICY

SSM Health Mid-Missouri Clinic Sites

PURPOSE:

To receive and report laboratory test results to the provider ordering the test and notification of the laboratory

results to the patient.

POLICY:

This policy is applicable to SSM Health Medical Group – Mid-Missouri (“MG-Mid-MO”) including its

employees, agents and medical staff, as well as employed physicians of an SSM Medical Group.

PROCEDURE:1. Test results exceeding critical limits are reported to the provider immediately upon the completion ofthe tests by reference laboratory personnel by telephone, followed by a written report. After hours, the provider on-call will be notified of results. The on-call provider should notify the patient’s provider with the follow-up that was done.

2. When results that exceed critical limits are reported to clinic personnel during office hours, the resultswill be written down, read back and verified by the clinic personnel receiving the results. All critical values are logged on the Critical Test Log. These are reported to the provider within 60 minutes.

3. Waived laboratory testing results done in the clinic laboratory are noted in the record and reported tothe ordering practitioners when the results are available.

4. Laboratory results which are not electronically sent to the provider’s result in-basket should bereviewed and placed in the provider in-box.

5. All results not received electronically shall be initialed and the follow-up action should be documentedin a note in the record and sent to the nurse pool for follow-up.

6. Normal results may be conveyed via phone or mail or MyChart. Abnormal results are called to the patient andrecorded in the record via a telephone encounter.

7. Any patient having an HIV antibody test will be notified before the test is drawn that they will becalled to return back to the clinic for results. HIV results are not to be given over the phone due to confidentiality.

8. Any test results not located in the patient's EHR should be labeled and forwarded to HIM to be scanned.

Source: Physician Services Laboratory Manual

Revision Date: 05/18

into the EHR after review and signature by the provider.