Form Doh 663-072 - Osteopathic Physician Assistant Remote Site Request Form (Page 2 of 2) in pdf

Form Doh 663-072 - Osteopathic Physician Assistant Remote Site Request Form Page 2

WAC 246-854-015

Supply a detailed plan for supervision and chart review as provided in

_______________________________________________________________________________________

Include an explanation of the community need for utilization of the osteopathic physician assistant in the

WAC 246-854-025

remote site. (Please see

Remote Site.)

_______________________________________________________________________________________

Explain the arrangement made for the osteopathic physician and certified osteopathic physician assistant to

communicate in emergent situations.

_______________________________________________________________________________________

We hereby certify under penalty of perjury under the laws of the State of Washington that the foregoing information

in this delegation agreement is correct to the best of our knowledge and belief. We further certify we have reviewed

the current rules and regulations of the Board of Osteopathic Medicine and Surgery pertaining to osteopathic

physician assistants and this practice description and understand our roles and responsibilities.

_______________________________________________________________

_______________________

Signature of Osteopathic Physician Assistant

Date

_______________________________________________________________

_______________________

Signature of Supervising Osteopathic Physician

Date

_______________________________________________________________

_______________________

Signature of Alternate Physician

Date

(Only required if single alternate supervisor is listed.)

Retain a copy of this form as reference and guide for review by a Department of Health representative in the event

of a site-review visit.

DOH 663-072 August 2016

Page 2 of 2

Form Doh 663-072 - Osteopathic Physician Assistant Remote Site Request Form Page 2