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Collaborative agreement nurse practitioner illinois pdf

Form collaborating physician 2026

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The document is a Notice of Collaborating Agreement between a Nurse Practitioner and a Physician, required for submission to eMedNY unless the Nurse Practitioner has over 3,600 hours of qualifying practice experience. It includes sections for the names and NPI numbers of both practitioners, the effective date of the agreement, and certification signatures confirming the establishment of a written collaborative agreement.

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Click ‘Get Form’ to open the form collaborating physician in the editor.
Begin by entering the 'Name of Nurse Practitioner' and their 'NPI' number in the designated fields. Ensure accuracy as this information is crucial for identification.
Next, fill in the 'Name of Collaborating Physician' and their corresponding 'NPI'. Remember, the physician must be enrolled in NY Medicaid for this agreement to be valid.
Indicate the 'Effective Date of Collaborating Agreement'. This date marks when the collaboration officially begins.
Both parties must sign in the provided signature fields. Ensure that signatures are original; stamps are not accepted. Include the date next to each signature for verification.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (51 Votes)
2009	4.3 Satisfied (48 Votes)

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What states do not require a collaborating physician?

The teaching physician attestation refers to documentation in the medical record that supports the teaching physicians presence and level of participation in the services provided to the patient.

What is a collaborating physician?

Final Takeaways: What Should You Pay? The real range for collaborating physician costs is $500 to $1,200 per month, with most agreements falling between $700 and $900. State rules, specialty, and prescriptive authority all impact pricing.

What does collaborating physician mean?

Nurse Practitioners can practice independently in the 27 states with full practice authority: Alaska, Arizona, Colorado, Connecticut, Delaware, Hawaii, Idaho, Iowa, Kansas, Maine, Maryland, Massachusetts, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oregon, Rhode Island,

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