Delegation agreement template 2026

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

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