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Delegation agreement template

Delegation agreement template 2025

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The document outlines the requirements and guidelines for a Delegation of Services Agreement between physician assistants and their supervising physicians in Utah. It details the necessary information to be included, such as names, licenses, practice sites, supervision methods, chart review frequency, and prescribing authority for controlled substances. The agreement must be maintained at each practice site and made available to the Department of Professional Licensing (DOPL) upon request. It emphasizes the importance of proper supervision and compliance with regulations to ensure patient safety.

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Click ‘Get Form’ to open the delegation agreement template in the editor.
Begin by entering the Physician Assistant's name and Supervising Physician's name in the designated fields. Ensure that all information is legible.
Fill in the Utah License Numbers for both the Physician Assistant and Supervising Physician, as well as any Substitute Supervising Physicians, if applicable.
List the practice sites by providing the name of each facility along with its address, city, state, and zip code.
Detail the degree and means of supervision required. Specify how immediate consultation will be conducted when not under direct supervision.
Outline the frequency and mechanism of chart review, ensuring clarity on onsite supervision expectations.
If applicable, include procedures for prescribing controlled substances and ensure compliance with licensing requirements.
Complete any additional sections regarding emergency procedures or considerations related to your practice.
Finally, gather signatures from all parties involved along with their respective dates to finalize the agreement.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a delegation agreement?

A delegation agreement is a written document that outlines the responsibilities and rights of both parties involved in the contract. In addition, the agreement ensures accountability, efficiency, and transparency in business dealings between two entities.

Is delegation legally binding?

Unless public policy or the contract itself bars the delegation, it is legally enforceable. In most states, at common law, duties must be expressly delegated.

What are the 3 Cs of delegation?

Youll stop bothering them with questions and emails about whether something was done. And it will give them the opportunity to shine and show you how much they accomplish. By adopting the 3 Cs of Delegation Confidence, Competence and Continuity you CAN multiply your results!