Form 08-4028b - Advanced Nurse Practitioner Consultation And Referral Plan
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2ADVANCED NURSE PRACTITIONER CONSULTATION AND REFERRAL PLAN
I. Description of Clinical Practice
Give a brief description of your clinical practice, including the geographical location, the clients you expect to see on a
routine basis, and the focus of care you will be offering.
II. Consultation/Referral
A. List your method of routine consultations and how these will be documented in the patient's record. Include names and
titles of health care providers you will utilize for consultation and referral. If your practice includes medical diagnosis
and treatment, include the name of at least one physician on the consultation referral list who is appropriate to your
focus of practice.
08-4028b (Rev. 8/00)
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