In general, the document outlines the rights and … Purpose The purpose of this document is to describe the scope of practice for the nurse practitioner (NP) who signs this agreement, as well as, provide written authorization by the supervising physician for the NP to initiate and provide psychiatric and medical care for the consumers of __________________________(agency) Registered Nurse Practitioner protocols. The law does not mandate a common CAPA-CS form. State law requires a career-long regulated collaborative agreement with another health provider in order for the NP to provide patient care, or it limits the setting of one or more elements of NP practice. A collaborative practice agreement typically contains the following information: This agreement shall take effect as of (date). 464.012(3), F.S. The advanced practice nurse is a nurse practitioner, clinical nurse specialist, certified nurse midwife, etc., with a specialized certification as a family nurse practitioner, etc. Box 2649. Complete names, home and business addresses, zip codes, and telephone numbers of the licensed practitioner and the advanced practice registered nurse: Licensed Practitioner: ST-NURSE@pa.gov Both myself and the above named physician have read and understand the regulations pertaining to prescriptive writing privileges (Federal and State prescribing laws including West Virginia Code for This agreement sets forth the terms of the Collaborative Practice Agreement between (nurse practitioner and specialty as listed on the State issued certificate) and (name of collaborating physician and specialty if any) at (name and address of agency or entity where practice takes place). KRS 314.196(2) states that if the Kentucky Board of Nursing and the Kentucky Board of Medical Licensure agree on a common CAPA-NS form, KBN shall require its use. A medical practitioner who provides obstetric services; or A medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement. �sQ� � [Content_Types].xml �(� Ė�j�@��}���%Y�PJ1zџ�V�}�uwbB��ew�{�NL���j�F�3�ov ��x]���ό�Y?� �4*��}M��GxZ��h���no�Ӎ�Z������s/S(���M�ĸB =�9�B~�9�A�����C,=�h��X������A�Y�\5�Y1��Hu���OJX'D����4���ߛPVԺ:�)&��(����S\�(H���i�$���K7���̋. Phone - (717) 783-7142 . An APRN and the collaborating physician may use any form as long as it meets the requirements of KRS 314.042(10). Currently in 2018, California state has found themselves entrenched in … A collaborative practice agreement is a document outlining this joint practice relationship between the nurse practitioner and physician. Harrisburg, PA 17105-2649 . Practice Authority: Nurse practitioners and physicians must enter a collaborative agreement for one or more elements of NP practice. A dated signature sheet signed by the primary supervising physician and the nurse practitioner will be appended to the Collaborative Practice Agr eement … An advanced registered nurse practitioner shall perform those functions authorized in this section within the framework of an established protocol which must be maintained onsite at the location or locations at which an advanced registered nurse practitioner … My collaborative agreement effective date is: _____. A collaborative arrangement for a participating nurse practitioner can be with all kinds of medical practitioners. Contact . All Protocols that have been received and reviewed by the Board can be found … The law do… Collaborative Practice Agreement (CPA) refers to the formal written statement addressing the parameters of the collaborative practice which are mutually agreed upon by the advanced practice registered nurse (APRN) and one or more licensed physician(s) or dentist(s). In general, the document outlines the rights and responsibilities of each party involved, formalizing the relationship. Please find below the complete application and additional forms needed to submit an APRN Protocol Agreement registration. The Common Collaborative Agreement for Advanced Practice Registered Nurse Prescriptive Authority for Non-Scheduled Drugs (CAPA-NS) Form is available in the Prescribing Nonscheduled Drugs (CAPA-NS) section below​ and shall be used by all APRNs who wish to enter into a CAPA-NS. A nurse practitioner provides the care at the center and they’re looking for a physician to form a collaborative agreement with the NP to meet state requirements. Collaborative Practice Agreement for Nurse Practitioner (SAMPLE) A. �' �' �' ¨' Ü( H $* Ä è* d gR iR iR iR iR iR iR $ ZV ¶ Y � �R ¡ ¬ L+ Ü( Ü( L+ L+ �R ¬ ¬ �' ¨' 4 .T ğ, ğ, ğ, L+ L ¬ �' ¬ ¨' gR ğ, L+ gR ğ, ğ, R J ô ÏL �' ÿÿÿÿ @H˜)ıÕ ÿÿÿÿ ˜+ K SR DT 0 tT %K ª  Y ®+ B  Y. Fax - (717) 783-0822. Collaborative Agreement CAPA-CS Form. The recruiter estimated that … State practice and licensure laws reduce the ability of NPs to engage in at least one element of NP practice. 4. nurse practitioner and main tained at the practice site. PK ! A sample of a form that meets these requirements can be found on the website of the Kentucky Association of Nurse Practitioners and Nurse … A collaborative practice agreement is a document outlining this joint practice relationship between the nurse practitioner and physician. P.O. 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