New Jersey Physician Assistant Delegation Agreement (V3.0 draft 9.23.16)

INSTRUCTIONS

  • In accordance with P.L. 2015 c.224, a delegation agreement may be executed by a single-specialty physician practice, provided it is signed by all of the delegating physicians supervising the physician assistant. 

    • In the case of a multi-specialty physician practice, a written delegation agreement may be executed for each physician specialty within the practice, provided it is signed by all of the delegating physicians supervising the physician assistant in that specialty area.  Note:the execution of a global written delegation agreement between a physician assistant and a multi-specialty physician practice is not permitted.

    • The full text of P.L. 2015 c.224 C.45:9-27.17 8.d. and e. is provided on page 1 of this agreement.

  • The delegation agreement must be signed and dated annually by the supervising physician(s) and the physician assistant and updated as necessary to reflect any changes in the practice or the physician assistant’s role in the practice.

  • This delegation agreement must be kept on file at the primary practice location and be submitted to the Physician Assistant Advisory Committee by mail within 30 days of the commencement of employment.

New Jersey Physician Assistant Advisory Committee

PO Box 183

Trenton, NJ 08625

P.L.2015, CHAPTER 224

C.45:9-27.17 

8. d.  A physician who supervises a physician assistant may maintain a written delegation agreement with the physician assistant.  A physician assistant shall sign a separate written agreement with each physician who delegates medical services in accordance with the provisions of subsection d. of section 7 of P.L.1991, c.378 (C.45:9-27.16).  However, a written delegation agreement may be executed by a single-specialty physician practice, provided it is signed by all of the delegating physicians supervising the physician assistant. In the case of a multi-specialty physician practice, a written delegation agreement may be executed for each physician specialty within the practice, provided it is signed by all of the delegating physicians supervising the physician assistant in that specialty area.  Nothing in this section shall authorize the execution of a global written delegation agreement between a physician assistant and a multi-specialty physician practice. The agreement shall: 

(1) state that the physician will exercise supervision over the physician assistant in accordance with the provisions of P.L.1991, c.378 (C.45:9-27.10 et seq.) and any rules adopted by the board;

(2) be signed and dated annually by the physician and the physician assistant, and updated as necessary to reflect any changes in the practice or the physician assistant’s role in the practice; and

(3) be kept on file at the practice site, be provided to the Physician Assistant Advisory Committee, and be kept on file by the committee.  

e. The delegation agreement shall include, but need not be limited to, the following provisions:

(1) The physician assistant’s role in the practice, including any specific aspects of care that require prior consultation with the supervising physician;

(2) A determination of whether the supervising physician requires personal review of all charts and records of patients and countersignature by the supervising physician of all medical services performed under the delegation agreement, including prescribing and administering medication as authorized under section 10 of P.L.1991, c.378 (C.45:9-27.19).  This provision shall state the specified time period in which a review and countersignature shall be completed by the supervising physician. If no review and countersignature is necessary, the agreement must specifically state such provision; and

(3) The locations of practice where the physician assistant may practice under the delegation agreement, including licensed facilities in which the physician authorizes the physician assistant to provide medical services.




Date________________

Physician Assistant name and license number

________________________________________________________________

Supervising physician(s) name(s) and license number(s)

________________________________________________________________

________________________________________________________________

________________________________________________________________


Practice name and primary address

_________________________________________

_________________________________________

_________________________________________

_________________________________________


Additional practice locations

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________


Supervising physician specialty/specialties

________________________________________

________________________________________



PHYSICIAN ASSISTANT ROLE IN THE PRACTICE

List all medical acts, beyond those explicitly stated in N.J.A.C. 13:35-2B.4, that the physician assistant may perform (examples include endotracheal intubation, lumbar puncture, obstetrical delivery and other diagnostic and therapeutic services and procedures).*  

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

*Hospital-based physician assistants may attach a copy or list of granted privileges in lieu of completing this section.


List any aspects of care that require prior consultation with the supervising physician.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


CO-SIGNATURE

Check one of the following:

  • Physician review and co-signature of charts and records is NOT required

  • Physician review and co-signature of charts of records IS required

If physician co-signature is required, state the time period in which the co-signature will be completed.

______________________________________________________________________________


SIGNATURES

In accordance with the provisions of P.L. 1991, 26 c.378 and the stipulations of this agreement, the above named physician(s) will exercise supervision over the above named physician assistant.   


Physician Assistant

____________________________________________________


Supervising physician(s)

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

















PHYSICIAN ASSISTANT DELEGATION AGREEMENT



This Physician Assistant Delegation Agreement dated as of __________________  and made effective as of this same date, (the "Agreement") is by and between ________________________  hereinafter referred to as the "PA" and the physicians as set forth on Schedule 1 attached hereto, hereinafter collectively referred to as the "Supervising Physicians."



1.Purpose. The purpose of this Agreement is to establish the delegating authority between the PA and the Supervising Physician(s) in accordance with New Jersey State laws and regulations.



2.Scope of Practice. The PAs scope of practice is as specifically set forth on the attached Exhibit A. PA acknowledges and agrees that the State of New Jersey regulates a PA's scope of practice, and that nothing in this Agreement confers, is intended to confer, or should be construed to confer authority for the PA to act beyond such regulatory scope. The PA agrees to provide services at all times within the scope of the PA's license and in compliance with all laws, rules and regulations of the State of New Jersey, including but not limited to, N.J.A.C. 13:35-2B.4 and N.J.S.A. 45:9-27.16, as amended from time to time.



3.Supervision Requirements. The Supervising Physicians will exercise supervision over the PA in accordance with all applicable laws and regulations, including but not limited to the New Jersey Physician Assistant Modernization Act and its implementing regulations, as amended from time to time. For purposes of this Agreement, as it relates to all settings, ''continuous supervision" means that the Supervising Physician need not be physically present, provided that a Supervising Physician maintains contact with the PA through electronic or other means of communication. The PA agrees and acknowledges that the PA is obligated to consult with a Supervising Physician when the PA has questions or concerns regarding patient treatment and management and/or when the patient's clinical condition requires medical decision-making beyond the PA's scope of practice, experience, or knowledge.



4.Medical Records & Review. The PA shall document in patient records in accordance with the policies and procedures of ______(name of medical group)__________,  and applicable laws and regulations. A Supervising Physician shall review select patient visit notes as medically appropriate.



5.Prescriptions. The PA may order, prescribe, dispense, and administer medications and medical devices to the extent delegated by the Supervising Physician, in accordance with applicable laws and regulations. Controlled dangerous substances may only be ordered or prescribed if the Supervising Physician has authorized the PA to order or prescribe such in accordance with N.J.S.A. 45:9-27.19.

 




6.Term and Termination. This Agreement shall remain in effect during the PA's employment by______(medical group name)____________. The parties agree to review the terms of this Agreement and Exhibit A on a periodic basis. In the event such employment Is terminated for any reason, or no reason, this Agreement shall automatically terminate. In the event the scope of practice of the PA changes, Exhibit A shall be modified accordingly and acknowledged.



7.Exhibits. Any exhibits and schedules referenced herein and attached hereto are expressly made a part of this Agreement as though fully set forth herein.



8.Counterparts. This Agreement may be executed in any number of counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same Instrument. Facsimile, email and other electronically delivered signatures of the undersigned parties to this Agreement shall have the same force and effect as, and shall be deemed to be, original signatures.










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____________________________           ________________

Physician AssistantDate



____________________________________________

Medical DirectorDate



CONTACT US

370 W Pleasant Ave Ste 2-239 Hackensack, NJ 07601
Mailing Address

njsspa@gmail.com
General Email


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