The law does not mandate a common CAPA-CS form. A dated signature sheet signed by the primary supervising physician and the nurse practitioner will be appended to the Collaborative Practice Agr eement … A collaborative arrangement is an arrangement between an eligible midwife/eligible nurse practitioner with a medical practitioner that must provide for: consultation with a specified medical practitioner; referral of a patient to a specified medical practitioner; and. 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. An APRN and the collaborating physician may use any form as long as it meets the requirements of KRS 314.042(10). Collaborative Agreement CAPA-CS Form. Fax - (717) 783-0822. Currently in 2018, California state has found themselves entrenched in … Complete names, home and business addresses, zip codes, and telephone numbers of the licensed practitioner and the advanced practice registered nurse: Licensed Practitioner: In general, the document outlines the rights and … 0 0 ¬ ¬ ¬ ¬ ¬ ÿÿÿÿ À À À 8 ø t l L À tT æ ¸ Ø Registered Nurse Practitioner protocols. 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) Both Boards agreed on the form in 2015. A sample of a form that meets these requirements can be found on the website of the Kentucky Association of Nurse Practitioners and Nurse … The review of the Collaborative Practice Agreement shall be done at least yearly. Please find below the complete application and additional forms needed to submit an APRN Protocol Agreement registration. A collaborative arrangement for a participating nurse practitioner can be with all kinds of medical practitioners. �' �' �' ¨' 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. In general, the document outlines the rights and responsibilities of each party involved, formalizing the relationship. Collaborative Practice Agreement for Nurse Practitioner (SAMPLE) A. PK ! Practice Authority: Nurse practitioners and physicians must enter a collaborative agreement for one or more elements of NP practice. Box 2649. All Protocols that have been received and reviewed by the Board can be found … 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). nurse practitioner and main tained at the practice site. P.O. A collaborative practice agreement is a document outlining this joint practice relationship between the nurse practitioner and physician. ST-NURSE@pa.gov Contact . 4. 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. Phone - (717) 783-7142 . The law do… Harrisburg, PA 17105-2649 . State practice and licensure laws reduce the ability of NPs to engage in at least one element of NP practice. �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���̋.