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SAMPLE WRITTEN COLLABORATIVE AGREEMENT DERIVED …

SAMPLE WRITTEN COLLABORATIVE AGREEMENT DERIVED FROM. (68 Ill. Adm. Code 1300. EXHIBIT A). ADVANCED PRACTICE NURSING. WRITTEN COLLABORATIVE AGREEMENT . A. ADVANCED PRACTICE NURSE INFORMATION. 1. NAME: 2. ILLINOIS RN LICENSE NUMBER: ILLINOIS APN LICENSE NUMBER: ILLINOIS MID-LEVEL PRACTITIONER CONTROLLED. SUBSTANCE LICENSE NUMBER: FEDERAL MID-LEVEL PRACTITIONER DEA NUMBER: 3. AREAS OF CERTIFICATION: 4. CERTIFYING ORGANIZATION: 5. CERTIFICATION EXPIRATION DATE: 6. CERTIFICATION NUMBER: 7. PRACTICE SITES: (Attach List of Sites). See Attachment A. 8. CONTACT NUMBER: FACSIMILE NUMBER: EMERGENCY CONTACT NUMBERS: ( , pager, answering service).

A written collaborative agreement is required for all Advanced Practice Nurses (APNs) engaged in clinical practice outside of a hospital, hospital affiliate, or ambulatory surgical treatment center (ASTC).

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