You can open the Collaborative Agreement Template for Nurse Practitioners in multiple formats, including PDF, Word, and Google Docs.
Collaborative Agreement Template For Nurse Practitioners Printable | Editable FormSample
[Name of the Nurse Practitioner]
[Nurse Practitioner’s ID]
[Nurse Practitioner’s Address]
[Nurse Practitioner’s Phone]
[Nurse Practitioner’s Email]
[Name of the Collaborating Physician]
[Physician’s ID]
[Physician’s Address]
This document formalizes the collaborative agreement between the Nurse Practitioner and the Collaborating Physician, effective as of [Effective Date], outlining the scope of practice and collaboration protocols.
The Nurse Practitioner will provide the following services: [List specific services provided, such as diagnostic, therapeutic, and health promotion services].
The Collaborating Physician agrees to provide supervision and consultation to the Nurse Practitioner as necessary, including [Specify details about availability and consultation frequency].
Regular communication will occur between the Nurse Practitioner and the Collaborating Physician to discuss patient care and treatment plans. Meetings will be scheduled [Specify frequency, e.g., weekly, monthly].
Both parties agree to coordinate care for patients, ensuring that consultations and referrals are made appropriately and documented accordingly.
Both the Nurse Practitioner and Collaborating Physician will engage in ongoing education and professional development to maintain clinical competency and adhere to best practices.
Both parties agree to indemnify one another from any claims arising out of the services provided under this agreement, except in cases of negligence or misconduct.
This agreement is effective from [Effective Date] and will continue until terminated by either party with [Notice Period] written notice.
This Agreement will be governed by the laws of [Jurisdiction].
[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 ID]
[Nurse Practitioner’s Address]
[Nurse Practitioner’s Phone]
[Nurse Practitioner’s Email]
[Name of the Collaborating Physician]
[Physician’s ID]
[Physician’s Address]
This collaborative agreement is intended to establish the working relationship between the Nurse Practitioner and the Collaborating Physician, effective from [Effective Date], detailing the services and responsibilities of each party.
The Nurse Practitioner will offer the following clinical services: [Specify services, e.g., patient assessments, treatment plans, follow-ups].
The Collaborating Physician will provide supervision and support whenever necessary, including direct consultations and reviews of patient care at [Specify frequency and method of consultation].
All patient care provided will be documented in accordance with [Specify regulatory requirements] and best practice guidelines.
Patients requiring specialist services will be referred to appropriate providers as necessary, with documentation of said referrals maintained by both parties.
Both parties agree to adhere to all applicable federal, state, and local laws and regulations governing the practice of nursing and medicine.
This agreement may be terminated if either party fails to fulfill their obligations, with [Notice Period] written notice required.
Both parties agree to keep all discussions, patient information, and proprietary information confidential, except as required by law.
In the event of a disagreement, both parties agree to pursue mediation before seeking legal recourse.
[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 Collaborative Agreement Template for Nurse Practitioners. All fields must be filled out to ensure a clear and complete agreement. We provide examples to guide you through each step. Collaborative Agreement Template for Nurse Practitioners 1. Nurse Practitioner Information 2. Physician Information 3. Agreement Purpose 4. Scope of Practice 5. Collaborative Practice Arrangements 6. Medication Management 7. Communication Protocol 8. Quality Assurance and Review 9. Termination of Agreement 10. Signatures and Acceptance 11. Declaration and Signatures
PDF
WORD
Collaborative Agreement Template For Nurse Practitioners Printable | Editable FormPrintable
