You can open the Tennessee Nurse Practitioner Collaborative Agreement Template in multiple formats, including PDF, Word, and Google Docs.
Tennessee Nurse Practitioner Collaborative Agreement Template Printable | Editable FormSample
[Name of the Nurse Practitioner]
[Nurse Practitioner’s License Number]
[Address of the Nurse Practitioner]
[Phone Number]
[Email]
[Name of the Collaborating Physician]
[Physician’s License Number]
[Address of the Physician]
This document outlines the collaborative agreement between the Nurse Practitioner and the Collaborating Physician. The agreement begins on [Effective Date] and will continue until terminated by either party.
The Nurse Practitioner is authorized to perform the following services under the collaborative agreement: [List Services].
The Collaborating Physician agrees to provide oversight and direction in the following areas: [Specify Areas of Oversight].
Regular communication will be maintained through: [Specify Methods and Frequency of Communication].
A quality assurance plan will be established to monitor the care provided by the Nurse Practitioner, including: [Describe Plan].
This agreement may be terminated at any time by either party with written notice of [Specify Notice Period].
[Signature of the Nurse Practitioner]
[Name of the Nurse Practitioner]
[Signature of the Collaborating Physician]
[Name of the Collaborating Physician]
[Name of the Nurse Practitioner]
[Nurse Practitioner’s License Number]
[Address of the Nurse Practitioner]
[Phone Number]
[Email]
[Name of the Collaborating Physician]
[Physician’s License Number]
[Address of the Physician]
This agreement sets forth the collaborative relationship between the Nurse Practitioner and the Collaborating Physician aimed at enhancing patient care services effective from [Effective Date].
The Nurse Practitioner will provide the following healthcare services: [List Specific Services].
The Collaborating Physician will be responsible for: [Specify Responsibilities].
Both parties agree to participate in continuing education meetings a minimum of [Specify Frequency], focused on relevant healthcare topics.
The Nurse Practitioner will maintain accurate patient records that are available for the Collaborating Physician’s review at any time.
Any modifications to this agreement must be made in writing and signed by both parties.
[Signature of the Nurse Practitioner]
[Name of the Nurse Practitioner]
[Signature of the Collaborating Physician]
[Name of the Collaborating Physician]
Form
Please complete the form below to create the Tennessee Nurse Practitioner Collaborative Agreement Template. All fields must be filled out to ensure a clear and comprehensive agreement. We provide examples to guide you through each step. Tennessee Nurse Practitioner Collaborative Agreement Template 1. Nurse Practitioner Information 2. Collaborating Physician Information 3. Agreement Details 4. Scope of Practice 5. Collaborative Practice Requirements 6. Supervision and Consultation 7. Prescriptive Authority 8. Termination Clauses 9. Signatures and Acceptance 10. Declaration and Signatures
PDF
WORD
Tennessee Nurse Practitioner Collaborative Agreement Template Printable | Editable FormPrintable
