APPLICATION CHECKLIST ADVANCED PRACTICE PROFESSIONALS

In order to process your credentialing application, please provide the information below as applicable. ☐ ADVANCED PRACTICE PROFESSIONAL CREDENTIALING APPLICATION: Please complete ALL sections of the

application. Provide accurate dates and addresses. You will be contacted regarding any information verified that is different than information provided on the application.

☐ CURRENT COPY OF ACLS, ATLS, BLS, PALS CERTIFICATION: (If applicable) ☐ CURRENT COPY OF BOARD CERTIFICATION: (Required for PAs, NPs, and CRNAs) ☐ DRUG ENFORCEMENT ADMINISTRATION LICENSE (DEA): (If applicable) Please provide copy of current Drug

Enforcement Administration license or recent application/renewal (i.e., copy of check, application form, letter from Drug Enforcement Administration).

☐ IDENTITY PROOFING FOR ELECTRONIC PRESCRIBING OF CONTROLLED SUBSTANCES (EPCS): (If

applicable) If you have your DEA License, EPCS eliminates the need for handwritten controlled substance prescriptions. To enroll, please bring a photo ID (Driver’s License or Passport) to the Medical Staff Administration Department located on the first floor of the Sherman Building located at the corner of Stockton Boulevard and Sherman Way, Suite 1700, between the hours of 7:30 and 5:00. No appointment necessary.

☐ PHOTO IDENTIFICATION: All applicants must submit copy of a current government issued photo I.D. ☐ CONTINUING EDUCATION (CEU): Please provide copy of current (within the past two years) Continuing Education

Units related to specialty. • Psychologist – 36 CEUs • Physician Assistant – 50 CEUs • Nurse Practitioner – 30 CEUs • Certified Registered Nurse Anesthetist – 30 CEUs

☐ JOB DESCRIPTION ☐ PAs Only

Delegation of Services Agreement between Supervising Physician and Physician Assistant PLUS Supervising Physician’s Responsibility of Supervision of Physician Assistant (3 pages): To be completed by Department, PA and Supervising Provider and signed accordingly. Department, PA and Supervising Provider to keep copies prior to forwarding to Medical Staff Admin.

☐ PAs Only Interdisciplinary Practice Committee notification of Schedule II Controlled Substance and Physician Assistant Schedule II Controlled Substance Prescribing (2 pages): Department to keep copies prior to forwarding to Medical Staff Admin.

☐ NPs Only

Standardized Procedures ☐ CURRICULUM VITAE

U.C. DAVIS MEDICAL CENTER CREDENTIALED ADVANCE PRACTICE PROFESSIONAL APPLICATION

PERSONAL INFORMATION DEPARTMENT INFORMATION

First Name: _________________________________________

Middle Name: _______________________________________

Last Name: _________________________________________

Title: _____ (CRNA, NP, PA, or PSYCHOLOGIST)

Birthdate: __________________________________________

Gender: __ M __ F __O

Social Security Number: _______________________________

Birth Place: _________________________________________ (City, State AND Country if not U.S.)

Home Address: ______________________________________

City: __________________________ State: ___ Zip: _______

Home Phone: _______________ Cell Phone: ______________

Best Email:__________________________________________

List all degrees types: ___________________________ (RN, NP etc.)

Language(s) spoken:

___________________________________________________ Other than English, sufficient to communicate with patients

Anticipated Start Date: _______________________________

Department: _______________________________________

Division (if applicable)________________________________

Specialty: __________________________________________

Clinic Address: ______________________________________

Office Address: _____________________________________

Office Phone: ____________ Pager Number:_____________

Supervising Provider: First Name: ________________________ Last Name: ________________________ Phone: ________________ Pager: ____________

Membership Category: ____ CRNA ____ NP ____ PA ____ PSYCHOLOGIST

Appointment: Employer: ________ School of Medicine _________ Hospital

LICENSES BOARDS and OTHER CERTIFICATIONS

NPI Number: _______________________________________

CA Professional License Number: _______________________

CA Professional License Number: _______________________

DEA Number #1: ____________________________________

DEA Number #2: ____________________________________

DEA Number #3: ____________________________________

X-Ray/Fluoroscopy Permit Number: _____________________

Plan to obtain X-Ray/Fluoroscopy Permit: _____Yes _____No

Other State Professional Licenses:

State: ___ License #: ___________ Expiration: ___________

State: ___ License #: ___________ Expiration: ___________

State: ___ License #: ___________ Expiration: ___________

State: ___ License #: ___________ Expiration: ___________

Certifying body_________________________________

Certified Date: ___________ Expiration Date: ____________

Certifying body __________________________________

Certified Date: ___________ Expiration Date: ____________

Certifying body __________________________________

Certified Date: ___________ Expiration Date: ____________

Other Certifications: ACLS, ATLS, BLS, PALS or other

Certification Name: _____________ Expiration Date: _______

Certification Name: _____________ Expiration Date: _______

Certification Name: _____________ Expiration Date: _______

Certification Name: _____________ Expiration Date: _______

Page 1 of 9

Name: ______________________________________________________________ NPI #: ____________________

UNDERGRADUATE SCHOOL

GRADUATE SCHOOL

CLINICAL TRAINING (IF APPLICABLE) ADDITIONAL CLINICAL TRAINING

Type of Training: ___________________________________ (Transitional, internship, residency, etc.)

Specialty: _________________________________________

From: ___________________ To _____________________

Facility: ___________________________________________

Address: __________________________________________

City: _____________________________________________

State: _______ Zip: __________________

Training Director Name: ______________________________ Provide only if training completed within last 5 years

Director Phone: _____________________________________

Director Fax: ________________________________________

Director Email: ______________________________________

Type of Training: ___________________________________ (Transitional, internship, residency, etc.)

Specialty: _________________________________________

From: ___________________ To _____________________

Facility: ___________________________________________

Address: __________________________________________

City: _____________________________________________

State: _______ Zip: __________________

Training Director Name: ______________________________ Provide only if training completed within last 5 years

Director Phone: _____________________________________

Director Fax: ________________________________________

Director Email: ______________________________________

PROFESSIONAL REFERENCES: List three peers who have knowledge of your clinical skills and abilities (If you completed training within last five years, one reference must be your training program director) (If applicable)

Peer #1 Name: _________________________________________________________ Degree: ________ Phone: _________________

Fax: ______________ Email: ______________________________________________________________________________

Peer #2 Name: _________________________________________________________ Degree: ________ Phone: _________________

Fax: ______________ Email: ______________________________________________________________________________

Peer #3 Name: _________________________________________________________ Degree: ________ Phone: _________________ Fax: ______________ Email: _______________________________________________________________________________

School Name: ___________________________________________________________________________________________

City or Country: ___________________________________________________________ State: ________________________ Type of Degree: __________ Graduation Date: ________________ ECFMG Number (foreign grad ONLY): _____________

School Name: ___________________________________________________________________________________________

City or Country: ___________________________________________________________ State: ________________________ Type of Degree: __________ Graduation Date: ________________ ECFMG Number (foreign grad ONLY): _____________

Page 2 of 9

Name: ______________________________________________________________ NPI #: ____________________

WORK HISTORY: List all patient care clinic related employment ONLY within previous 5 years

From: ___________________ To _____________________

Facility: ___________________________________________

Address: __________________________________________

City: _____________________________________________

State: _______ Zip: __________________

Phone: _______________ Director Fax: _______________

Director Email: _____________________________________

From: ___________________ To _____________________

Facility: ___________________________________________

Address: __________________________________________

City: _____________________________________________

State: _______ Zip: __________________

Phone: _______________ Director Fax: _______________

Director Email: _____________________________________

From: ___________________ To _____________________

Facility: ___________________________________________

Address: __________________________________________

City: _____________________________________________

State: _______ Zip: __________________

Phone: _______________ Director Fax: _______________

Director Email: _____________________________________

From: ___________________ To _____________________

Facility: ___________________________________________

Address: __________________________________________

City: _____________________________________________

State: _______ Zip: __________________

Phone: _______________ Director Fax: _______________

Director Email: _____________________________________

From: ___________________ To _____________________

Facility: ___________________________________________

Address: __________________________________________

City: _____________________________________________

State: _______ Zip: __________________

Phone: _______________ Director Fax: _______________

Director Email: _____________________________________

From: ___________________ To _____________________

Facility: ___________________________________________

Address: __________________________________________

City: _____________________________________________

State: _______ Zip: __________________

Phone: _______________ Director Fax: _______________

Director Email: _____________________________________

*ADD ANY ADDITIONAL EMPLOYMENT LOCATIONS ON A SEPARATE SHEET AND ATTACH TO APPLICATION

Page 3 of 9

Name: ______________________________________________________________ NPI #:____________________

If you answer yes to any questions below, please explain in section below. Question Yes No Has your professional license or registration in any jurisdiction or your DEA registration ever been voluntarily or involuntarily revoked, suspended or limited in any manner or is any such action pending?

☐ ☐

Has there ever been an involuntary termination of employment or involuntary limitation, reduction, denial or loss of clinical actions at another health care organization or is any such action pending?

☐ ☐

Have you ever resigned from a health care organization to avoid disciplinary action or is any such action pending? ☐ ☐ Have you ever been subject to disciplinary action in any health care organization or is any such action pending? ☐ ☐ Have you ever been convicted or pleaded guilty or nolo contendere related to the practice of health care, including fraud or abuse relating to any government health program or third party reimbursement or is any such action pending?

☐ ☐

Have you ever been convicted or pleaded guilty or nolo contendere to any crime (other than a minor traffic violation)? ☐ ☐ Are you currently excluded from participation in any federal or state healthcare program, have you ever been excluded or is any such action pending?

☐ ☐

Do you currently use drugs illegally? ☐ ☐

Use this box for explanation of any yes answers to questions above:

Provider Malpractice History: In the past five years have you been involved in any legal claims relating to alleged medical malpractice (e.g., notice of intent to sue, named or served defendant, final judgments or settlements, etc.) ☐ Yes* ☐ No

*If Yes to malpractice question above you MUST complete the "Professional Malpractice History Summary Form" foreach malpractice occurrence. (One form per occurrence)

Health Question: Have you any current impairment, disability, or transmittable disease that could affect your clinical performance or your ability to provide safe and quality patient care, with or without reasonable accommodation, according to accepted standards? ☐ Yes ☐ No

*If Yes to health question above please explain, in section below:

Page 4 of 9

Name: ______________________________________________________________ NPI #: ____________________

Certification and Agreement: I understand and agree as follows:

I certify that the health statement question has been answered to the best of my ability. I agree to report any changes in my physical or mental health that could affect my ability to provide safe and quality patient care.

I agree to notify Medical Staff Administration within 14 days of any disciplinary action, including those reported by other health care organizations to my state licensing board and/or National Practitioner Data Bank; I agree to notify the Medical Staff Administration immediately upon being informed of exclusion from any state or federal health care program.

I certify that the information provided by me in this application is correct and complete to the best of my knowledge and belief. Any significant misstatements or omissions from this application constitutes’ cause for denial or termination of employment. I am given the right to review information obtained from outside sources, such as state licensing boards and the National Practitioner Data Bank, but do not have the right to review references, recommendations or other information that is peer review protected. I have the right to correct erroneous information and to be informed of the status of my application upon request.

I present this application, and arrange for the submission of other information as part of this credentialing process, in the expectation that the confidentiality and privacy of this information will be preserved, and that this information and these materials will only be released or disclosed as part of the current and future credentialing, peer review and performance improvement processes described in the UCDMC Bylaws and Rules and Regulations of the Medical Staff.

Confidentiality is vital to the free and candid communication necessary for effective performance improvement activities, peer review, and consideration of the qualifications of clinical staff to perform specific procedures. I agree to respect and maintain the confidentiality of all discussion, deliberations, records and any other information generated in connection with these activities by the Medical Staff, departments, divisions or their committees. I shall only disseminate the foregoing where expressly required by law, pursuant to officially adopted policies of UCDMC and the Medical Staff, or where no officially adopted policy exists, only with the express approval of the Medical Staff Executive Committee or its designee. I shall make no voluntary disclosures or such discussions, deliberations, records and information except to persons authorized to receive it in the conduct of UCDMC and Medical Staff affairs. In the event of a breach or threatened breach of this confidentiality agreement, the University may, as applicable and as it deems appropriate, pursue University procedures and/or take any other action available to the University to address such noncompliance. UCDMC policies and procedures and the Medical Staff Bylaws include confidentiality provisions.

I acknowledge that I have read and agree to comply with the Bylaws and Rules and Regulations of the Medical Staff of the University of California, Davis Medical Center and agree to comply with applicable hospital policies of the University of California, Davis Medical Center and the University's Health Sciences Clinical Enterprise Code of Conduct. I further agree not to participate in the division of fees, and to maintain an ethical practice and provide continuous care for my patients. I agree to participate in the teaching program of the University of California, Davis Medical Center.

Pursuant to the Federal Privacy Act of 1974, I am hereby notified that disclosure of my Social Security number is voluntary. The Social Security number is used to verify identity, and shall not be disclosed except as permitted by law. This record keeping system was established pursuant to the authority of the Regents of the University of California, under Article IX, Section 9, of the California Constitution.

Provider Signed: __________________________________________________ Date: ________________________

Department Chair or Designee Signature: ___________________________________ Date: ____________________

Interdisciplinary Practice Committee Recommendation: The following signature indicates that the Interdisciplinary Practice Committee has reviewed this application and recommends this individual.

Interdisciplinary Practice Committee Chair: ________________________________________________________ Date: ____________________

Page 5 of 9

Name: ______________________________________________________________ NPI #: ____________________

RELEASE AND CERTIFICATION STATEMENT

My signature below authorizes the Regents of the University of California or their representatives to contact individuals, agencies, and health care facilities that I have listed on my application for Advanced Practice Professionals credentialing or recredentialing. I agree to release the University of California from civil liability regarding the processing of my application. Further, I hereby release from liability any and all individuals and organizations that provide information to the University of California, Davis Medical Center or its Medical Staff in good faith without malice concerning my professional competence ethics, character, and other qualifications for staff membership and clinical privileges and I hereby consent to the release of such information. I certify that the information provided in my request for credentialing or recredentialing at the University of California, Davis Medical Center is true and correct to the best of my knowledge and belief.

Signature: __________________________________________________________ Date:___________________

Page 6 of 9

Name: ______________________________________________________________ NPI #: ____________________

MALPRACTICE STATEMENT OF RELEASE AND CARRIER INFORMATION

Please provide the names and addresses of all professional liability insurance carriers you have had for the past five years. Sign and date this Release and print or type your name below your signature. PROFESSIONAL LIABILITY INSURANCE CARRIER(S):

Carrier Name: ______________________________________

From: ___________________ To _____________________

Policy Number: _____________________________________

Phone: ___________________ Fax: ____________________

Carrier Name: ______________________________________

From: ___________________ To _____________________

Policy Number: _____________________________________

Phone: ___________________ Fax: ____________________

Carrier Name: ______________________________________

From: ___________________ To _____________________

Policy Number: _____________________________________

Phone: ___________________ Fax: ____________________

Carrier Name: ______________________________________

From: ___________________ To _____________________

Policy Number: _____________________________________

Phone: ___________________ Fax: ____________________

I authorize all malpractice carriers to release coverage and/or claims history information:

Credentials Unit - Sherman Building, Suite 1700Medical Staff AdministrationUC Davis Medical Center2315 Stockton BoulevardSacramento, CA 95817

Additionally, if my policy is cancelled for any reason, or if changes are made in my coverage amounts, I request that no such cancellation or change be made without thirty (30) days prior notice to UC Davis Medical Center at the address above. I understand that this information will be used during the evaluation process for credentialing/recredentialing at UC Davis Medical Center. I further understand that this information will only be disclosed to those authorized to receive it by the Bylaws of the Medical Staff.

Signature: ______________________________________________________ Date: __________________________

Page 7 of 9

PROFESSIONAL MALPRACTICE HISTORY SUMMARY

Provider Name: ___________________________________________ Occurrence #: ______ of _______

Patient’s age: ____ Patient’s gender: ____ Occurrence date: ________________________________________

Place of Occurrence: ___________________________________________________________________________

Provide details of malpractice case, including patient’s diagnosis, procedure performed (if any), allegation of wrongdoing, provider's level of involvement (e.g., attending, resident, etc.), and any explanation relevant to provider’s role. May email additional information if needed:

Current status of Case:

__ Open __ Settled __ Closed without payment __ Judgment in favor of defendant

__ Judgment in favor of plaintiff __ Provider dropped from case due to non-involvement

__ Arbitration __ Other: _______________________________

I have filled out the above items or have reviewed for accuracy.

Signature: ________________________________________________________ Date: __________________

Page 8 of 9

University of California, Davis Medical Center Confidential - Protected by Evidence Code 1157

CONFIDENTIAL REFERRAL AND FINANCIAL INTEREST QUESTIONNAIRE

Instructions: Federal and state law prohibit physicians from making referrals to entities for certain services if the provider or an immediate family member has a financial relationship with the entity, unless a particular exception applies. In addition, federal and state law also prohibits anyone from receiving payment for either referring a patient or buying goods or services (a “kickback”). There are exceptions to each of these rules. Contact UCDMC Legal Affairs if you have concerns.

YES  NO 

1. Have you referred any patient to a non-University of California individual or entity that you,your department or an immediate family member has any financial relationship(ownership/investment interest or compensation arrangement)?

2. Have you, your department, or an immediate family member received a gift, compensation, orother remuneration from any individual or entity to which you referred a patient?

3. Have you, your department, or an immediate family member received a gift, compensation orother remuneration for any individual or entity in exchange for using their health relatedproduct or service?

If the answer is to any of the questions above was “YES”, describe the nature of services and the economic interest or remuneration involved.

I have filled out the above items or have reviewed for accuracy.

Signature: Date:

Printed Name:

Page 9 of 9

Page 1 of 3

DELEGATION OF SERVICES AGREEMENT BETWEEN SUPERVISING PHYSICIAN AND PHYSICIAN ASSISTANT (Title 16, CCR, Section 1399.540)

PHYSICIAN ASSISTANT______________________________________________________________ Physician Assistant, graduated from the ___________________________________________________ Physician Assistant training program on _____________. The Physician Assistant took (or is to take) the licensing examination for Physician Assistants recognized by the State of California (e.g., Physician Assistant National Certifying Examination or a specialty examination given by the State of California) on ____________.

The Physician Assistant was first granted licensure by the Physician Assistant Committee on ____________, which expires on _______________, unless renewed. SUPERVISION REQUIRED. The Physician Assistant named above (hereinafter referred to as PA) will be supervised in accordance with the written supervisor guidelines required by Section 3502 of the Business and Professions Code and Section 1399.545 of the Physician Assistant Regulations. The written supervisor guidelines are incorporated with the attached document entitled, "Supervising Physician's Responsibility for Supervision of Physician Assistants." AUTHORIZED SERVICES. The PA is authorized by the physician whose name and signature appear below to perform all the tasks set forth in subsections (a), (d), (e), (f), and (g) of Section 1399.541 of the Physician Assistant Regulations, when acting under the supervision of the herein named physician. (In lieu of listing specific lab procedures, etc. the PA and supervising physician may state as follows: "Those procedures specified in the practice protocols or which the supervising physician specifically authorizes.") The PA is authorized to perform the following laboratory and screening procedures: __________________________________________________________________________________________

__________________________________________________________________________________________ The PA is authorized to assist in the performance of the following laboratory and screening procedures: __________________________________________________________________________________________

__________________________________________________________________________________________ The PA is authorized to perform the following therapeutic procedures: __________________________________________________________________________________________

__________________________________________________________________________________________ The PA is authorized to assist in the performance of the following therapeutic procedures: __________________________________________________________________________________________

__________________________________________________________________________________________ The PA is authorized to function as my agent per bylaws and/or rules and regulations of (name of hospital): __________________________________________________________________________________________

__________________________________________________________________________________________ a) The PA is authorized to write and sign drug orders for Schedule: II, III, IV, V without advance approval (circle authorized Schedule(s). The PA has taken and passed the drug course approved by the PAC on __________ (attach certificate). DEA #:______________________________. or b) The PA is authorized to write and sign drug orders for Schedule: II, III, IV, V with advance patient specific approval (circle authorized Schedule(s). DEA #:______________________________.

Page 2 of 3

CONSULTATION REQUIREMENTS. The Physician Assistant is required to always and immediately seek consultation on the following types of patients and situations (e.g., patient's failure to respond to therapy; physician assistant's uncertainty of diagnosis; patient's desire to see physician; any conditions which the physician assistant feels exceeds their ability to manage, etc.) _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ (List Types of Patients and Situations) MEDICAL DEVICES AND PHYSICIAN'S PRESCRIPTIONS. The Physician Assistant may transmit by telephone to a pharmacist, and orally or in writing on a patient's medical record or a written prescription drug order, the supervising physician's prescription in accordance with Section 3502.1 of the Business and Professions Code. The supervising physician authorizes the delegation and use of the drug order form under the established practice protocols and drug formulary. ________ YES _________ NO The PA may also enter a drug order on the medical record of a patient at ___________________________________________

(Name of Institution) in accordance with the Physician Assistant Regulations and other applicable laws and regulations. Any medication handed to a patient by the PA shall be authorized by the supervising physician's prescription and be prepackaged and labeled in accordance with Sections 4076 of the Business and Professions Code. PRACTICE SITE. All approved tasks may be performed for care of patients in this office or clinic located at _________________________________________ and, in _______________________________________ hospital(s) and

(Address/City) (Address/City) ________________________________________________________ skilled nursing facility (facilities) for care of (Name of Facility) patients admitted to those institutions by physician(s) ______________________________________________________

(Name/s)

EMERGENCY TRANSPORT AND BACKUP. In a medical emergency, telephone the 911 operator to summon an ambulance. The ___________________________________________ emergency room at __________________________________

(Name of Hospital) (Phone Number) is to be notified that a patient with an emergency problem is being transported to them for immediate admission. Give the name of the admitting physician. Tell the ambulance crew where to take the patient and brief them on known and suspected health condition of the patient. Notify _____________________________________ at ___________________________________ immediately

(Name of Physician) (Phone Number/s) (or within ________________ minutes). PHYSICIAN ASSISTANT DECLARATION My signature below signifies that I fully understand the foregoing Delegation of Services Agreement, having received a copy of it for my possession and guidance, and agree to comply with its terms without reservations. _________ ________________________________________/_________________________________________ Date Physician's Signature (Required) & Physician's Printed Name _________ ________________________________________/__________________________________________ Date Physician Assistant's Signature (Required) & Physician Assistant's Printed Name

Page 3 of 3

SUPERVISING PHYSICIAN'S RESPONSIBILITY FOR SUPERVISION OF PHYSICIAN ASSISTANT

SUPERVISOR______________________________________________________________________, M.D/D.O. is licensed to practice in California as a physician and surgeon with medical license number _________________. Hereinafter, the above named physician shall be referred to as the supervising physician.

SUPERVISION REQUIRED. The Physician Assistant (PA) named in the attached Delegation of Services Agreement will be supervised by the supervising physician in accordance with these guidelines, set forth as required by Section 3502 of the Business and Professions Code and Section 1399.545 of the Physician Assistant Regulations, which have been read by the physician whose signature appears below.

The physician shall review, countersign, and date within seven (7) days the medical record of any patient cared for by the physician assistant for whom the physician's prescription for Schedule II medications was transmitted or carried out. REPORTING OF PHYSICIAN ASSISTANT SUPERVISION. Each time the Physician Assistant provides care for a patient and enters their name, signature, initials, or computer code on a patient's record, chart or written order, the Physician Assistant shall also enter the name of their supervising physician who is responsible for the patient. When the Physician Assistant transmits an oral order, they shall also state the name of the supervising physician responsible for the patient. MEDICAL RECORD REVIEW. One or more of the following mechanisms, as indicated below, by a check mark (x), shall be utilized by the supervising physician to partially fulfill their obligation to adequately supervise the actions of the Physician Assistant named _________________________________________________________. ___ Examination of the patient by a supervising physician the same day as care is given by the PA.

___ The supervising physician shall review, audit, and countersign every medical record written by the PA within _______ of the encounter. (Number of Days May- Not Exceed 30 Days) ___ The physician shall audit the medical records of at least 5% of patients seen by the PA under any protocols which shall be adopted by the supervising physician and the PA. The physician shall select for review those cases which by diagnosis, problem, treatment, or procedure represent, in their judgment, the most significant risk to the patient.

___ Other mechanisms approved in advance by the Physician Assistant Committee may be used. Written documentation of those mechanisms is located at ________________________________________________. (Give Location) ___ INTERIM APPROVAL. For Physician Assistants operating under interim approval, the supervising physician shall review, sign, and date the medical records of all patients cared for by the Physician Assistant within seven (7) days if the physician was on the premises when the Physician Assistant diagnosed or treated the patient. If the physician was not on the premises at that time, they shall review, sign, and date such medical records within 48 hours of the time the medical services were provided.

BACK UP PROCEDURES: In the event this supervising physician is not available when needed, the following physician(s) has (have) agreed to be a consultant(s) and/or to receive referrals:

___________________________________________________________Phone: _________________________ (Printed Name and Specialty)

___________________________________________________________Phone: _________________________ (Printed Name and Specialty)

PROTOCOLS NOTE: This document does not meet the regulation requirement to serve as a protocol. Protocols, if adopted by the supervising physician, must fully comply with the requirements authorized in Section 3502(c)(1) of the Business and Professions Code.

_________________ __________________________________________________________________ Date Physician's Signature

Interdisciplinary Practice Committee

Dear Sir/Madam

The Interdisciplinary Practice Committee (IDP) is responsible for credentialing allied health practitioners

including Physician Assistants (PAs), according to current California Law. Recently Senate Bill-337

Physician Assistants was updated regarding supervision of PAs.

The new requirement is:

(e) The supervising physician and surgeon shall use either of the following mechanisms to ensure

adequate supervision of the administration, provision, or issuance by a physician assistant of a drug

order to a patient for Schedule II controlled substances:

You may choose either of these mechanisms:

1. The medical record of any patient cared for by a physician assistant for whom the physician

assistant’s Schedule II drug order has been issued or carried out shall be reviewed,

countersigned, and dated by a supervising physician and surgeon within seven days.

2. If the physician assistant has documentation evidencing the successful completion of an education

course that covers controlled substances, and that controlled substance education course (A)

meets the standards, including pharmacological content, established in Sections 1399.610 and

1399.612 of Title 16 of the California Code of Regulations, and (B) is provided either by an

accredited continuing education provider or by an approved physician assistant training

program.

The supervising physician and surgeon shall review, countersign, and date, within seven days, a

sample consisting of the medical records of at least 20 percent of the patients cared for by the

physician assistant for whom the physician assistant’s Schedule II drug order has been issued or

carried out.

Completion of the requirements set forth in this paragraph shall be verified and documented in

the manner established in Section 1399.612 of Title 16 of the California Code of Regulations.

Physician assistants who have a certificate of completion of the course described in paragraph

(2) of subdivision (c) shall be deemed to have met the education course requirement of this

subdivision.

You are designated as the supervising physician to a PA, to comply with Senate Bill-337 please identify

the Schedule II drugs prescribed by the PA you supervise and provide the reasons for prescribing and a

list of contraindications.

Thank you

Toby Marsh, RN, MSA, MSN, FACHE, NEA-BC

Chief Patient Care Services Officer

Interdisciplinary Practice Committee Chair

1

UC Davis Medical Center

2315 Stockton BoulevardSacramento, CA 95817

health.ucdavis.edu

Physician Assistant: ____________________________________ DEA #___________________

Department: ___________________________________________________________________

Supervising Physician: __________________________________ DEA # __________________

Schedule II Controlled

Substance

Reasons for prescribing Contraindications

Signed: _____________________________________________ Date: _____________________

2

UC Davis Medical Center

2315 Stockton BoulevardSacramento, CA 95817

health.ucdavis.edu