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NURSE PRACTITIONER WRITTEN COLLBORATIVE …

STATE OF MARYLAND TYPE YOUR NAME (AS IT APPEARS ON YOUR LICENSE) NURSE PRACTITIONER WRITTEN COLLBORATIVE agreement This Document Must Be Typed Please review the online instructions before completing this document. You Must Attach This Page To Your agreement or Addendum NEW agreement SUBMIT PAGES 1 THROUGH 14 (WITH ORIGINAL SIGNATURES ON PAGE 14) (A resume, copies of CDS and DEA licenses, and copies of current CPR, ACLS, PALS and/or NRP certifications must be submitted with each New agreement .) ADDENDUM (REVISED/AMENDED agreement ) Resumes are not required with Addendums (CHECK ANY OF THE FOLLOWING THAT APPLY) ADDITION OF A PHYSICIAN OR CHANGE IN PHYSICIAN COLLABORATORS (SAME PRACTICE OR ORGANIZATION).

the purpose of this agreement is to reflect the understanding between the nurse PRACTITIONER AND PHYSICIAN (S) AS RELATED TO THE ADVANCED PRACTICE ACTIVITIES OF THE NURSE PRACTITIONER AND THE NATURE OF THEIR MUTUAL COLLABORATION.

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