Agreement Entered on * (Date)

¶ … Agreement entered on * (date) between *, APN and * institution (afterwards referred to as 'the Parties') is as follows:

APN is duly licensed as an advanced practice nurse under * (state's) Law and is duly recognized under the aforesaid law as capable of engaging in advanced practice nursing and she also holds a graduate degree that is approved by the Board of Nursing.

Therefore APRN and * Physician each recognize the compatibility of each other and desire to enter into the Nurse Protocol agreement that is applicable with the * (state) law's and regulations.

Now, therefore, the parties agree as follows

General requirements

Description of Parties to the Agreement (Names / contact info.)

Description of the practice

C, Physician warrants that he will provide the APRN's DEA number to the Board within thirty (30) days of its issuance.

II Consultation

A. Physician shall be available to APRN for immediate consultation by telephone or by other telecommunications. In the event physician is not available, another readily located and specified physician will take his place.

III. Duties

In rendering her services, APRN shall exercise the required amount of care as defined by her profession and requirements of her profession and evidence the degree of skill, care and diligence that is expected of advanced nurse practitioners under similar circumstances and to this specific patient population

Physician delegates to APRN the authority to perform the delegated acts expected of her position

1. Any prescription legalized by physician will be issued in a form which contains the name of the APRN; the APRN's DEA number; the drug or device prescribed; the number of refills and directions to the patients with regard to the taking and dosage of the drugs; and must be signed b the APRN and include the names of the APRN and physician who are Parties to this Agreement.

2. APRN has the authority to order such drugs, medical devices, and medical treatments or in life-threatening situations anything appropriate for the situation.

VI. Execution and Amendment

A. Any amendment to the nurse protocol agreement will be filed with the Board within 30 days of issuance.

B. The nurse protocol agreements will be available for review by the * Board of Nursing.