PHYSICIAN ASSISTANT SUPERVISORY …

1 PHYSICIAN ASSISTANT SUPERVISORY agreement Strong Memorial: _____ Highland Hospital: _____ (Please indicate which hospital this agreements applies to) The Department of _____, employing _____, PA, with privileges and procedures as approved by the department, Medical Executive Committee and Board as detailed on the Delineation of Privileges, will be supervised by Dr. _____. In the interest of the hospital and the patients it serves, this agreement shall define the scope of practice as applying those privileges and procedures for any patients admitted to or cared for by any PHYSICIAN with privileges in the department of _____ to the fullest extent of the knowledge and competence of the PA and in accordance with good practice, the bylaws of the medical staff applicable codes and laws, and consultation with PHYSICIAN .

2 PHYSICIAN ASSISTANT : _____ PA NYS License #: _____ Supervising PHYSICIAN Signature: _____ PHYSICIAN NYS License #: _____ Date: _____ ** Please return to (by US mail): Please return to (by intramural mail): Medical Staff Office Medical Staff Office Attention: PAEC Attention: PAEC 120 Corporate Woods, Suite 350 Box 278911 Rochester, NY 14623 Please return by fax to: (585)-784-8367 Please direct any questions to (updated e-mail address).