Commencement For Collaborative Practice Page 2
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2ALABAMA BOARD OF MEDICAL EXAMINERS
Commencement
For Collaborative Practice
Mailing Address:
Physical Address:
P.O. Box 946
848 Washington Avenue
Montgomery, AL 36101-0946
Montgomery, AL 36104
Phone: 334-242-4116
Toll Free: 1-800-227-2606
Website:
**
Send this signed original document and $100.00 fee to the Alabama Board of Medical Examiners.
Alabama Board of Medical Examiners
Attn: Collaborative Practice Department
Phone: 334-242-4116
(Use one page per CRNP/CNM. Make additional copies as needed)
1. Physician’s Name:
License Number:
2. Practice Address:
3. CRNP/CNM Name:
License Number:
4. CRNP/CNM Practice Address:
5. Date services to begin under this Collaborative Agreement _
This is to certify that I, the undersigned physician agree and/or confirm:
1.
The nurse practitioner/nurse mid-wife above and I will complete chart reviews for Quality
Assurance as per the plan below and agree that 100% of all adverse actions will be reviewed for
Quality Assurance.
2. The covering physicians listed in the application have knowledge and understanding of the
Collaborative Practice Rules [Chapter 540-X-8] and be aware of their responsibilities.
3. Have an emergency plan/ policy in writing at the practice site.
Quality Assurance Plan:
A. Who will complete the chart reviews?
Physician
Nurse Practitioner
Other
B. What is the time frame for your review?
Weekly
Monthly
Quarterly
C. Selection of records for review to include records for patients treated by the CRNP/CNM
D. Describe criteria for selecting records to be reviewed (give detail):
I the undersigned physician have read and understand the Alabama Board of Medical Examiners
Rules, Chapter 540-X-8, Advanced Practice Nursing: Collaborative Practice. It is also understood that
my signature attests to these facts. Failure to adhere to these rules may result in an action against
my license. It is also understood that I will complete written Termination upon the dissolution of
this Collaborative Agreement.
PHYSICIAN’S SIGNATURE:
DATE:
(Original Signature Only)
Print Physician Name:
DATE:
**To alleviate a delay in approval of the Collaborative Practice fill out the form completely and send upon submission of the application to the
Board of Nursing. This Commencement Form will be returned if all of the information is not present and a check attached for the required fee.
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