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INSTRUCTIONS - Collaborative Plan

Complete all parts of the plan – print legibly or type. Incomplete plans will not be accepted.

Attach a copy of the physician assistant’s current NCCPA certificate.

Attach a copy of the physician assistant’s valid DEA registration.

Attach a copy of the physician’s valid DEA registration.

Attach a detailed curriculum vitae for the PA, if applicable, for remote site practice.

Receipt No.

Amount

Include a check payable to the state of Alaska in the amount of $150.

Mail the completed plan with all attachments to the State Medical Board,

3601 C Street, Suite 722, Anchorage, AK 99503-5934.

TO QUALIFY FOR REMOTE SITE PRACTICE

Physician Assistants with less than two years of full-time clinical experience:

Must work 160 hours in direct patient care under the direct and immediate supervision of the primary collaborating physician or an

alternate.

The first 40 hours must be completed before going to the remote site practice; the remaining 120 hrs must be completed within 90

days of going to the remote site practice.

___ Hours of supervision will commence as soon as this plan is approved and prior to practicing at the remote site. The completed

Verification of Hours of Supervision form will be sent to the State Medical Board immediately upon completion of the required hours.

[Physician: Initial this statement if applicable.]

- OR -

Physician assistants with more than two years of full-time clinical experience:

Must attach a detailed curriculum vitae which describes the education, skills, and experience sufficient to meet the needs and

demands of the remote site practice.

Upon my careful review, as primary collaborating physician, it is my opinion that the previous experience of the physician assistant

documented in the attached curriculum vitae has adequately prepared and qualified this individual to work at the remote site practice

location identified in this plan.

Primary Collaborating Physician Signature

__________________________________________________________

IMPORTANT REGULATIONS (See Booklet for Complete Regulations Language)

PERFORMANCE AND ASSESSMENT OF PRACTICE

[12 AAC 40.430 (d)]

It is understood by the physician and the physician assistant that a periodic method of assessment is or will be established which will

include the physician’s evaluation of physician assistant’s work performance with at least two days each quarter of direct and personal

contact and through at least monthly telephone or radio communications to review patient care, records, and charts. It is further

understood that documentation of such periodic assessments may be audited by the State of Alaska at any time.

COMMUNICATIONS WITH SENSORY-IMPAIRED PATIENTS

[12 AAC 40.980(A)(4)]

A method is or will be devised whereby a physician assistant’s level of education and professional training are communicated to

patients who may be blind, deaf, or otherwise impaired.

IDENTIFICATION OF PHYSICIAN ASSISTANT

[12 AAC 40.460]

It is understood that the physician assistant will wear on his/her clothing a nameplate identifying them as a “Physician Assistant-

Certified” and shall display a sign at the place of employment which posts current state licensure and that documents of the Physician

Assistant’s education and plan of collaboration are available for inspection.

PRESCRIPTIVE AUTHORITY

[12 AAC 40.450]

Prescribing Schedules III, IV, and V

[12 AAC 40.450(c)]

The physician assistant named in this plan may, with a valid DEA registration, write a prescription for a schedule III, IV, or V controlled

substance medication with primary collaboration physician’s approval.

Order, Administer and Dispense Schedule II

[12 AAC 40.450(d)]

The physician assistant named in this plan may order, administer, and dispense a schedule II controlled substance medication with

primary collaboration physician’s approval.

Obtaining Controlled Substance Samples

[12 AAC 40.450(e)]

The physician assistant named in this plan may use the physician assistant’s own DEA registration number to request,

receive, order, or procure a controlled substance medication sample from a pharmaceutical distributor, warehouse, or

other entity only with primary collaboration physician’s approval.

Prescribe, Order, Administer, or Dispense Non-Controlled Medications

[12 AAC 40.450(f)]

The physician assistant named in this plan may prescribe, order, administer, or dispense a medication that is not a controlled substance

only with primary collaboration physician’s approval.

LIABILITY

[12 AAC 40.980(a)(6)]

By signing this document on the reverse side, the collaborating physician is acknowledging acceptance of complete personal or

employer liability to a patient of the physician assistant for whom malpractice is adjudged.

08-4226 e (Rev 11/2000)

Page 2 of 2

Form 08-4226 - Application For Physician Assistant - Alaska Department Of Community And Economic Development Page 9

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