Assignment: Supervising Physicians

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Assignment: Supervising Physicians

Assignment: Supervising Physicians

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title, Florida license number/DEA #999999 (or other description of designated

authorized supervising physician), will serve as backup for consultation, collaboration and/or referral purposes.

VI. Specific Conditions and Requirements for Direct Evaluation With respect to specific conditions and procedures that require direct evaluation, collaboration, and/or consultation by the physician, the following will serve as a reference guide:

Clinical Guidelines in Family Practice, X Edition, by Constance R. Uphold, ARNP, PhD, and Mary Virginia Graham, ARNP, PhD

(or other reference text or practitioner created reference guide) OR The physician will be consulted for the following conditions:

3rd degree lacerations

Severe hypertension determined by _

Etc. (list appropriate conditions)

VII. All parties to this agreement share equally in the responsibility for reviewing treatment protocols as needed. (At practice locations where multiple physicians or dentists are supervising the same ARNPs, the practice may delegate to one of the supervising physicians or dentists the authority to sign the protocol for the physicians or dentists listed on the protocol)

Signature /

(Printed Name), ARNP Date

Signature /

(Printed Name), Title Date


Effective June 23, 2017, under HB453, in accordance with 464.012 Florida Statutes, practicing ARNPs must maintain their protocol

onsite at their place of employment. The Board of Nursing will no longer be required to receive, review, or maintain Advanced

Registered Nurse Practitioner protocols.

464.012(3), F.S. An advanced registered nurse practitioner shall perform those functions authorized in this section within the

framework of an established protocol which must be maintained onsite at the location or locations at which an advanced registered

nurse practitioner practices. In the case of multiple supervising physicians in the same group, an advanced registered nurse

practitioner must enter into a supervisory protocol with at least one physician within the physician group practice.

The supervising physician is responsible for submitting a notice to the Board of Medicine that they have entered into a supervisory

relationship with an ARNP.


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