Form 08-4226 - Application For Physician Assistant - Alaska Department Of Community And Economic Development Page 8

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ALASKA STATE MEDICAL BOARD
PHYSICIAN ASSISTANT COLLABORATIVE PLAN
Physician Assistant
______________________________________________
Lic No._____________
Address of Record
______________________________________________
PA - Permanent Change of
______________________________________________
Address?
No
Yes
Telephones
Wk___________________
Hm____________________
Primary Physician
______________________________________________
Lic No._____________
Address
______________________________________________
______________________________________________
Telephones
Wk___________________
Hm____________________
Alternate Physician
______________________________________________
Lic No._____________
Address
______________________________________________
______________________________________________
Telephones
Wk___________________
Hm____________________
Signature, Alternate
_____________________________________________
Alternate Physician
______________________________________________
Lic No._____________
Address
______________________________________________
(Attach an addendum with
______________________________________________
additional alternates if
Telephones
Wk___________________
Hm____________________
needed.)
Signature, Alternate
_____________________________________________
Practice Location
____________________________________________________________________
Remote Practice
No
Yes - Physician assistant is qualified for remote practice (sign back of form).
Prescriptive
12 AAC 40.450 (c) Prescribe Schedule III, IV, and V
Authority
12 AAC 40.450 (d) Order, Administer, Dispense Schedule II
12 AAC 40.450 (e) Procure Controlled Substance Samples
12 AAC 40.450 (f) Prescribe, Order, Dispense, Administer Non-controlled Drugs
Requirements of Law The physician assistant will work only within the agreed scope of practice with the primary
physician. All parties to this plan agree to comply with the provisions of all statutes and
regulations relating to the physician assistant’s practice of medicine in Alaska.
_______________________________________
_______________________________________
Signature, Physician Assistant
Date
Signature, Primary Collaborating Physician
Date
NOTARY
NOTARY
SUBSCRIBED AND SWORN before me, a Notary Public in and for
SUBSCRIBED AND SWORN before me, a Notary Public in and for
the state of Alaska, this ______ day of _____________, _____.
the state of Alaska, this ______ day of _____________, _____.
________________________________________
__________________________________________
Notary Public
Notary Public
My commission expires_________________________________
My commission expires_________________________________
(Notary Seal)
(Notary Seal)
STAFF TEMPORARY
APPROVAL__________________________________________________
Date_______________________
Permit No._________________
08-4226 d (Rev 11/2000)
Page 1 of 2

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