Written Collaborative Practice Agreement Advanced Practice ... Documents/FORM...2016/01/25 · APN. 1.2 PHYSICIAN hereby delegates to APN the authority to administer, dispense and

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Last updated on January 25, 2016 by Chris Wintrode, Assistant General Counsel - Contracts, Governance & Policy

Written Collaborative Practice Agreement – Advanced Practice Nurse

Instructions Sheet

Outlined in this document are the instructions for completing the “Written Collaborative Practice

Agreement – Advanced Practice Nurse” and forming a Collaborative Practice Agreement between a Physician

and Advanced Practice Nurse. The Guide to Written Collaborative Practice Agreements – Advanced Practice

Nurse - Illinois can also help to address questions that may arise regarding specific terms. For further questions

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

1. Page 1: Using the Written Collaborative Practice Agreement – Advanced Practice Nurse fill in all fields

appropriately. The effective date is the date the collaboration is to commence between the Physician and

APN.

2. Page 2: 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 check “No” to both boxes Exhibit 7.

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 and complete Exhibit 7.

3. Page 3: Section 1.3, Delegation of Controlled Substance Authority – indicate what schedules of substances

are authorized by delegation.

4. Page 3: Section 1.5, Clinical Privileges - Indicate what SSM Health hospital privileges shall extend from

the physician to APN.

5. Page 10: 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.

6. Page 11: 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. 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.

7. Page 13: 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

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responsibility of collaboration. All Designated Physicians’ should indicated their acknowledgement of this

duty and receipt of the Agreement via signature.

8. Page 14: 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.

9. Page 16: 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 five (5) FTE

APNs.

10. Page 18: Exhibit 7, Controlled Substance Authority – If controlled substance authority has been delegated

by the Agreement, the supervising physician must complete Exhibit 7 indicating what restrictions are

applicable. In the event of Schedule II authority, a physician may only delegate five Schedule II substances to

the APN upon filing of the proper registrations with the DEA and State Board of Nursing.

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

manager and to the 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 is readily available for any agency inspection.

Version 11/10/15 Page 1 of 19

WRITTEN COLLABORATIVE PRACTICE AGREEMENT ADVANCED PRACTICE NURSE

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

WHEREAS, PHYSICIAN is licensed in Illinois and employed by PHYSICIAN EMPLOYER to provide PHYSICIAN SPECIALTY medical services, and APN is licensed in Illinois as a 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 Illinois 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 clinics or offices PRACTICE SITE in a manner consistent with APN’s skill, training, competence and professional judgment and Illinois collaborative practice law.

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

WHEREAS, a written collaborative agreement is required for all advance practice nurses engaged in clinical practice outside of a hospital or ambulatory surgical treatment center;

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

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 PHYSICIAN to collaboratively practice

under the terms of this Agreement.

APN shall not, under any circumstances, prescribe controlled substances. The required consultation and PHYSICIAN’s (or, if applicable, Designated Physicians') directions for the administering or dispensing of controlled substances shall be recorded in the patient’s chart and in the appropriate dispensing log. These recordings shall be made by APN and shall be cosigned by PHYSICIAN (or the Designated Physicians, if applicable) following a review of the records.

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1. Delegation of Authority.

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

1.2 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 Section 1.2 and Exhibit 7 of this Agreement is subject to the following conditions:

(a) Delegation of Prescriptive Authority:

i.

By marking “Applies”, PHYSICIAN hereby affirms that APN has not been delegated any authority to prescribe controlled substances or any other substance 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 ofAgreement. APN shall not, under any circumstances, prescribe controlledsubstances or any drug that the PHYSICIAN is not qualified or authorized toprovide. The required consultation and PHYSICIAN’s directions for theadministering or dispensing of controlled substances shall be recorded in thepatient’s chart and the appropriate dispensing log. These recordings shall benoted by APN and shall be co-signed by PHYSICIAN following reviewofthe records.

PHYSICIAN hereby asserts that he/she has a valid current Illinois controlledsubstance license and federal registration to delegate authority to prescribedelegated controlled substances. PHYSICIAN hereby delegates to APN theauthority to administer, dispense, and prescribe drugs in accordance withjointly established written protocols, standing orders and the terms of thisAgreement. The foregoing delegation may include the prescribing,administration and dispensing of Schedule III, III-N, IV, and V controlleddrugs as well as legend drugs. To prescribe controlled substances, APNmust have an Illinois mid-level practitioner controlled substance license inaccordance with Illinois regulations. The foregoing delegation may also

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include the prescribing of Schedule II or II-N controlled substances if all of the following conditions apply: (i) no more than five (5) Schedule II or II-N controlled substances by oral dosage may be delegated (generic substitution pursuant to Section 25 of the Pharmacy Practice Act shall be allowed when not prohibited by a prescriber’s indication on the prescription that the pharmacist “may not substitute”), (ii) any delegation must be controlled substances that PHYSICIAN prescribes, (iii) any prescription must be limited to no more than a 30-day oral dosage, with any continuation authorized only after prior approval of PHYSICIAN, (iv) the APN must discuss the condition of any patients for whom a controlled substance is prescribed monthly with PHYSICIAN, and (v) the advanced practice nurse meets the education requirements of Section 303.05 of the Illinois Controlled Substances Act.

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) All prescriptions written and signed by APN shall indicate the name of the collaborating physician. The APN shall sign his/her own name.

1.3 Delegation of Controlled Substance Authority:

PHYSICIAN hereby delegates to APN the authority to administer, dispense and prescribe controlled substances in accordance with the schedules below and reflected in Exhibit 7; 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) applies to this agreement.

Authorized Not Authorized Authorized Not Authorized Authorized Not Authorized Authorized Not Authorized

Schedule II-N:Schedule II: Schedule III-N: Schedule III: Schedule IV: Schedule V: 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 Illinois Nurse 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.

1.5 If applicable, APN shall maintain allied health personnel privileges at the following hospitals:

SSM Health St. Mary’s Hospital - CentraliaSSM Health Good Samaritan Hospital - Mt. Vernon

Authorized Not Authorized

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1.6 A copy of this Agreement shall remain on file at all sites where APN renders services and shall be provided to the Illinois Department of Financial and Professional Regulation upon request.

2. Practice Sites.

PHYSICIAN and APN’s practice is located at the Practice Site(s) set forth on Exhibit 3.

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 periodically review the work records and practice of the APN in accordance with accepted standards of medical practice and advanced nursing practice. 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. PHYSICIAN shall meet in person with APN at least once per month for case review and to provide consultation and collaboration.

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.

4. Terms and Conditions.

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

4.2 Each party represents and warrants to the other party that each party and its owners, employees, agents and any subcontractors (collectively “Personnel”) are not: (i) listed on the System for Award Management website (“sam.gov”) with an active exclusion; or (ii) suspended or excluded from participation in any federal health care programs, as defined under 2.U.S.C. § 1320a-7b(f), any form of state Medicaid program, and are not listed on the Office of the Inspector General’s website (“oig.hhs.gov”) (collectively, “Government Payor Programs”). Each party also represents and warrants that to the best of its knowledge there are no pending or threatened governmental investigations that may lead to suspension or exclusion of each party or 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 other party of the commencement of any Investigation or suspension or exclusion from Government Payor Programs within three (3) business days of each party’s 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 timely kept apprised by each party of the status of any such Investigation. Each party shall indemnify, defend, and hold other party harmless from any claims, liabilities, fines, and

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expenses (including reasonable attorneys’ fees) incurred as a result of each 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 annually by the 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 APN EMPLOYER 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 APN EMPLOYER, or between PHYSICIAN and PHYSICIAN EMPLOYER;

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

(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.

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.

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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 APN EMPLOYER 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 APN EMPLOYER 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.

APN EMPLOYER 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 APN EMPLOYER 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 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.

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8.2 Limitation on Collaborative Arrangements.

PHYSICIAN shall not enter into written collaborative agreements with more than five (5) 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, APN EMPLOYER 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, APN EMPLOYER 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 APN EMPLOYER, nor shall PHYSICIAN be entitled to any benefits to which APN as an employee of APN EMPLOYER 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 APN EMPLOYER are independent contractors, and this Agreement shall not constitute the formation of a partnership, joint venture, employment or master-servant relationship.

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.

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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 Illinois without regard to Illinois’ 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 Notices.

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 APN EMPLOYER’s confidential methods of operations, pricing policies, marketing strategies, trade secrets, knowledge, techniques, data and other information about APN’s EMPLOYER’s operations and business of a confidential nature (“Confidential Information”) and that such Confidential Information has a special and unique value to APN EMPLOYER. 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 APN EMPLOYER, any of such Confidential Information. Upon the expiration or termination by any party for any reason of this Agreement, PHYSICIAN shall immediately return to APN EMPLOYER any and all such Confidential Information in possession or control of PHYSICIAN.

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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.

APN and PHYSICIAN acknowledge that APN EMPLOYER is an equal opportunity employer. As part of APN’s EMPLOYER’s affirmative action policies and obligations, APN EMPLOYER is subject to and will comply with the provisions governing federal contractors as set forth in 41 CFR 60-1.4(a), 41 CFR 60-741.5(a) and 41 CFR 60-250.5(a), and these regulations are hereby incorporated into this Agreement by reference.

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 applicable 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.

[Remainder of Page Intentionally Left Blank - Signature Page to Follow]

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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:

Name: Name:

Physician / Date:_________ APN / Date:_________





ANNUAL REVIEW (Please initial and date):

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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 in this Agreement.

Insert Physician / APN jointly reviewed protocol below:

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EXHIBIT 1 Continued

REFERENCES, GUIDELINES, PROTOCOLS AND STANDING ORDERS

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EXHIBIT 2

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.

____________________________________________ ____________________________________________ Name Date Name Date






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EXHIBIT 3

PRACTICE LOCATIONS

Designate Collaboration Practice Site with an asterisk or other identifying mark.

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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.

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EXHIBIT 5

WRITTEN PRACTICE AGREEMENTS

Physician Written Collaborative Agreements:

Primary Collaborating Physician

APN Written Collaborative Agreements:

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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 shall consult with PHYSICIAN within a medically appropriate time frame. In emergency situations, the APN may consult with Designated Physicians, or any PHYSICIAN with the appropriate specialty.

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EXHIBIT 7

CONTROLLED SUBSTANCE AUTHORITY

Pursuant to Section 65-40(d) of the Illinois Nurse Practice Act, a collaborating physician may, but is not required to, delegate authority to an advanced practice nurse to prescribe Schedule II or II-N controlled substance under the following conditions:

1. The collaborating physician can only delegate controlled substances that the collaboratingphysician prescribes.

2. Medication orders shall be reviewed periodically by the collaborating physician.

3. An APN who has been given controlled substances prescriptive authority shall be required toobtain an Illinois mid-level practitioner controlled substances license in accordance with 77 Ill.Adm. Code 3100. The physician shall file a notice of delegation of prescriptive authority with theDivision. The delegation of authority form shall be submitted to the Division prior to theissuance of a controlled substance license.

Delegation of prescriptive authority for controlled substances in this Agreement includes:

Schedule III-N, III, IV, and V: Yes No

Delegation, pursuant to Section 1.3 of this Agreement, includes prescription of, selection of, orders for, administration of, storage of, acceptance of samples of, and dispensing over the counter medications, legend drugs, and controlled substances categorized as Schedule III, III-N, IV or V controlled substances, as defined in Article II of the Illinois Controlled Substances Act, and other preparations, including, but not limited to, botanical and herbal remedies.

Schedule II or II-N controlled substances: Yes No

Delegation, pursuant to Section 1.3 of this Agreement, includes no more than five (5) Schedule II or II-N controlled substances by oral dosage, topical or transdermal application. Schedule II controlled substances to be delivered by injection or other route of administration may not be delegated. For the purposes of this Agreement, generic substitution pursuant to Section 25 of the Pharmacy Practice Act shall be allowed when not prohibited by a prescriber's indication on the prescription that the pharmacist "may not substitute.”

Specific brand or generic name of delegated Schedule II controlled substances:

Drug 1:________________________________________________________________________

Drug 2:________________________________________________________________________

Drug 3:________________________________________________________________________

Drug 4:________________________________________________________________________

Drug 5:________________________________________________________________________

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EXHIBIT 7 Continued

Schedule II or II-N controlled substances continued:

Any prescription must be limited to no more than a 30-day oral dosage, with any continuation authorized only after prior approval of the collaborating physician.

APN must discuss the condition of any patients for whom a controlled substance is prescribed monthly with the delegating physician.

APN may only prescribe and dispense controlled substances that the collaborating physician prescribes.

All prescriptions written and signed by an advanced practice nurse shall indicate the name of the collaborating physician and the collaborating physician's signature is not required. The APN nurse shall sign his/her own name.

An APN may receive and dispense samples per the collaborative agreement.

The Illinois Advanced Practice Nurse controlled substance license is a prerequisite for the federal controlled substance registration. After receiving an Illinois Controlled License, the APN must apply for a Federal Drug Enforcement Administration (DEA) permit.