Looking for a Alaska Legal Forms And Templates? Download it for free!

Form 08-4226 - Application For Physician Assistant - Alaska Department Of Community And Economic Development Page 13

________________________________________________

_____________________________________________

Physician Assistant

Primary Collaborating Physician

Instructions:

Utilize this form to add alternate collaborating physicians to the collaborative plan between the PA-C and

the physician shown above.

ALTERNATE COLLABORATING PHYSICIAN’S STATEMENT

I hereby certify that I am familiar with the statutes and regulations of the State of Alaska governing the activities and

responsibilities of a collaborating physician and that I will fulfill those responsibilities in this collaborative agreement in the

absence of the primary collaborating physician. In entering into this agreement as alternate collaborating physician, I

accept professional or employer liability to patients of the physician assistant for whom malpractice is adjudged. I have

retained a copy of this agreement for my records. I will also maintain and make available for audit by the State of Alaska

any performance assessment records which are generated as a result of this collaborative agreement in my capacity as

alternate collaborating physician.

Signature

Date

Printed Name

AK License No.

Address

City

State

Zip

Telephone

Signature

Date

Printed Name

AK License No.

Address

City

State

Zip

Telephone

Signature

Date

Printed Name

AK License No.

Address

City

State

Zip

Telephone

Signature

Date

Printed Name

AK License No.

Address

City

State

Zip

Telephone

08-4226 i (Rev 11/2000)

Form 08-4226 - Application For Physician Assistant - Alaska Department Of Community And Economic Development Page 13

Related Articles

Related forms

Related Categories