PHYSICIAN ASSISTANT'S RESPONSIBLE PHYSICIAN …

1 PHYSICIAN ASSISTANT'S RESPONSIBLE PHYSICIANand DRUG PRESCRIPTION PROTOCOL Please enter required information, including signatures and dates on page 2 and page or fax ASSISTANT'S Name:License Number: RESPONSIBLE PHYSICIAN 's Name::License of the PHYSICIAN 's practice and way in which the physicianassistant is to be utilized (please include the routine duties of the physicianassistant, the type of practice, and the practice setting) locations, including hospitals, at which the PHYSICIAN assistant willroutinely perform acts constituting the practice of medicine and understand the RESPONSIBLE PHYSICIAN will always be available forcommunication with the PHYSICIAN assistant within 30 minutes during theperformance of patient service by the PHYSICIAN understand that failure to adequately direct and supervise the physicianassistant in accordance with PHYSICIAN assistant Licensure Act, or rulesand regulations adopted under such statutes by the board, wouldconstitute grounds for revocation, suspension.

2 Limitation or censure of theresponsible PHYSICIAN 's license to practice medicine and surgery in thestate of understand a current copy of this form shall be provided to the Boardoffice and maintained at the usual practice locations of the responsiblephysician and that any changes or amendments thereto will be provided tothe board within 10 is a completed Drug Prescription Protocol Form provided by theboard which specifies categories of drugs, medicines and pharmaceuticalsfor which the PHYSICIAN assistant is prohibited from supplying signature of a designated PHYSICIAN who shall routinely providedirection and supervision to the PHYSICIAN assistant in the temporaryabsence of the RESPONSIBLE PHYSICIAN is required:Signature of Designated PhysicianName of Designated the procedures to be followed to notify the designated physicianupon such temporary absence of the RESPONSIBLE PHYSICIAN .

3 I have carefully read the questions in the foregoing request form and haveanswered them completely, and I declare under penalty of perjury that myanswers and all statements contained herein are true and of RESPONSIBLE PhysicianSignature of PHYSICIAN AssistantDateDate2 License Number:Date800 SW Jackson, Lower Level-Suite A., TOPEKA KS 66612 Voice: 785-296-7413 Toll Free: 1-888-886-7205 Fax: 785-296-0852 Website: Drug Prescription Protocol as authorized by the RESPONSIBLE PHYSICIAN must be submitted to theBoard for the PHYSICIAN assistant to prescribe drugs or request, receive, sign for and distribute topatients professional samples.

4 Further, in no case shall the scope of the authority of thephysician assistant to prescribe drugs, exceed the normal and customary practice of theresponsible PHYSICIAN in the prescribing of drugs. To prescribe controlled substances, thephysician assistant must register with the Drug Enforcement PHYSICIAN assistant is authorized to prescribe controlled substances as follows:NONEALLALL EXCEPTS pecify belowSchedule II and II-NSchedule III and III-NScheduleIVScheduleVExceptions:INFOR MATION PERTAINING TO DEA REGISTRATIONYESNOR esponsible PHYSICIAN has a current DEA number? PHYSICIAN assistant has a current DEA number?

5 RESPONSIBLE PHYSICIAN and PHYSICIAN assistant have DEA registrations for prescribing ofcontrolled substances in all schedules?If the answer is "no" to any of the above, please provide explanation:3 PHYSICIAN ASSISTANT'S Name:License Number: RESPONSIBLE PHYSICIAN 's Name:License Number:4 The PHYSICIAN assistant is authorized to prescribe non-controlled drugs as follows:NONEW ithinClassALLW ithinClassALLE xceptSpecifyBelowAnalgesics (non-narcotic)AnthelminthicsAntibioticsA ntifungalsAntihistaminesAntihypertensive sAntinauseantsAntispasmodicsBronchodilat orsContraceptivesCough SuppressantsCardiac DrugsDecongestantsDiureticsExpectorantsE strogensProgesterone PreparationsHemorrhoidal PreparationsInjectablesSkeletal Muscle RelaxantsTopical Ophthalmic Preparations, Except SteroidsOtic PreparationsVaginitis PreparationsVitamins and MineralsTopical PreparationsSteroidsAnti-Anxiety and Anti-DepressantsOther (SPECIFY BELOW)Other/Exceptions.

6 The PHYSICIAN ASSISTANT'S authority to request, receive and sign for professional samples and todistribute professional samples to patients is identical to the PHYSICIAN ASSISTANT'S authority toprescribe non-controlled substances, except:Signature of PHYSICIAN AssistantSignature of RESPONSIBLE PhysicianDateDaterevised 1-25-11, kl800 SW Jackson, Lower Level-Suite A., TOPEKA KS 66612 Voice: 785-296-7413 Toll Free: 1-888-886-7205 Fax: 785-296-0852 Website.