You can open the Ohio Nurse Practitioner Collaborative Agreement Template in multiple formats, including PDF, Word, and Google Docs.
Ohio Nurse Practitioner Collaborative Agreement Template Printable | Editable FormSample
[Name of the Nurse Practitioner]
[Nurse Practitioner’s License Number]
[Nurse Practitioner’s Address]
[Nurse Practitioner’s Phone]
[Nurse Practitioner’s Email]
[Name of the Collaborating Physician]
[Physician’s License Number]
[Physician’s Address]
This agreement sets forth the collaborative practice relationship for the Nurse Practitioner and Collaborating Physician, effective as of [Contract Start Date].
The Nurse Practitioner shall be authorized to perform services in accordance with Ohio law and shall include: [List specific services].
The Collaborating Physician will oversee the Nurse Practitioner’s services and will provide guidance as necessary, ensuring high standards of care.
The parties agree to maintain regular communication, including monthly meetings to discuss patient care and operational issues.
Both parties shall maintain appropriate professional liability insurance and will provide proof of such to each other annually.
This agreement may be terminated by either party with [Number] days’ written notice, outlining the reasons for termination.
This agreement shall be governed by the laws of the State of Ohio.
[Signature of the Nurse Practitioner]
[Name of the Nurse Practitioner]
[Signature of the Collaborating Physician]
[Name of the Collaborating Physician]
[Name of the Nurse Practitioner]
[Nurse Practitioner’s License Number]
[Nurse Practitioner’s Address]
[Nurse Practitioner’s Phone]
[Nurse Practitioner’s Email]
[Name of the Collaborating Physician]
[Physician’s License Number]
[Physician’s Address]
This document establishes a collaborative agreement that outlines the roles and responsibilities of the Nurse Practitioner and the Collaborating Physician in Ohio.
The Nurse Practitioner shall provide the following medical services: [List services, e.g., diagnosis, treatment, health education].
The Nurse Practitioner has the authority to make clinical decisions in line with the collaborative agreement and Ohio law.
Both parties will review the terms of this agreement annually and update it as needed to comply with changes in regulations or practice standards.
Both parties agree to indemnify and hold each other harmless from any claims arising from their respective practices.
This agreement shall be effective as of [Effective Date] and shall remain in effect for [Duration], unless terminated as specified herein.
[Signature of the Nurse Practitioner]
[Name of the Nurse Practitioner]
[Signature of the Collaborating Physician]
[Name of the Collaborating Physician]
Form
Please complete the form below to create the Ohio Nurse Practitioner Collaborative Agreement Template. All fields must be filled out to ensure a clear and complete agreement. We provide examples to guide you through each step. Ohio Nurse Practitioner Collaborative Agreement Template 1. Nurse Practitioner Information 2. Collaborating Physician Information 3. Agreement Overview 4. Scope of Practice 5. Collaborative Practice Restrictions 6. Responsibilities of the Nurse Practitioner 7. Responsibilities of the Collaborating Physician 8. Communication and Consultation Protocol 9. Termination Clauses 10. Signatures and Acceptance 11. Declaration and Signatures
PDF
WORD
Ohio Nurse Practitioner Collaborative Agreement Template Printable | Editable FormPrintable
