A.

ADVANCED PRACTICE NURSE INFORMATION

1.

NAME:

2.

ILLINOIS RN LICENSE NUMBER:

ILLINOIS APN LICENSE NUMBER:

ILLINOIS MID-LEVEL PRACTIONER LICENSE NUMBER:

FEDERAL MID-LEVEL PRACTITIONER DEA NUMBER:

3.

AREAS OF CERTIFICATION:

4.

CERTIFYING ORGANIZATION:

5.

CERTIFICATION EXPIRATION DATE:

6.

CERTIFICATION NUMBER:

7.

PRACTICE SITES: See Attachment A.

8.

CONTACT NUMBER:

FACSIMILE NUMBER:

EMERGENCY CONTACT NUMBERS:

(e.g., pager, answering service)

9.

ATTACHMENTS:

Copy of Certification/Recertification

Copies of RN & APN License

Copy of Certificate of Insurance

Copy of Mid-Level Practitioner License

B.

COLLABORATING PHYSICIAN INFORMATION

1.

NAME:

2.

ILLINOIS LICENSE NUMBER:

3.

PRACTICE AREA OR CONCENTRATION:

4.

BOARD CERTIFICATION (if any):

5.

CERTIFYING ORGANIZATION:

6.

PRACTICE SITES: See Attachment:

7.

CONTACT NUMBER:

FACSIMILE NUMBER:

EMERGENCY CONTACT NUMBERS:

(e.g., pager, answering service)

C.

ADVANCED PRACTICE NURSE COLLABORATING PHYSICIAN WORKING

RELATIONSHIP

1.

SCOPE OF PRACTICE

Under this agreement, the advanced practice nurse will work with the collaborating physician in an active practice to deliver health care services to_______________.  This includes, but is not limited to, the diagnosis, treatment and management of acute and chronic health problems; ordering, interpreting and performing laboratory and radiology tests; prescribing medications, including controlled substances, to the extent delegated; receiving and dispensing stock and sample medications; performing other therapeutic or corrective measures as indicated.

If applicable, the advanced practice nurse shall maintain allied health personnel privileges at the following hospitals for the designated services:

Hospitals:

This written collaborative agreement shall be reviewed and updated annually. A copy of this written collaborative agreement shall remain on file at all sites where the advanced practice nurse renders service and shall be provided to the Illinois Department of Financial and Professional Regulation upon request. Any joint orders or guidelines are set forth or referenced in Attachment B.

2.

MEDICAL DIRECTION

Physician medical direction shall be adequate with respect to collaboration with Certified Nurse Practitioners, Certified Nurse Midwives, and Certified Clinical Nurse Specialists if a collaborating physician:

(A)

participates in the joint formulation and joint approval of orders or guidelines with the advanced practice nurse and periodically reviews those orders and the services provided patients under those orders in accordance with accepted standards of medical practice and advanced practice nursing practice;

(B)

is on site at least once a month to provide medical direction and consultation; and

(C)

is available through telecommunications for consultation on medical problems, complications, or emergencies or patient referral. (See 225 ILCS 60/54.5(6).)

The written collaborative agreement shall be for services the collaborating physician generally provided to his or her patients in the normal course of clinical practice. Medical direction for a Certified Registered Nurse Anesthetist shall be adequate if:

(A)

an anesthesiologist or a physician participates in the joint formulation and joint approval of orders or guidelines and periodically reviews those orders and the services provided patients under those orders; and

(B)

for anesthesia services, the anesthesiologist or physician participates through discussion of and agreement with the anesthesia plan and is physically present and available on the premises during the delivery of anesthesia services for diagnosis, consultation, and treatment of emergency medical conditions.  Anesthesia services in a hospital shall be conducted in accordance with Section 10.7 of the Hospital Licensing Act and in an ambulatory surgical treatment center in accordance with Section 6.5 of the Ambulatory Surgical Treatment Center Act.  (See 225 ILCS 60/54.5(b-5).)

3.

COMMUNICATION, CONSULTATION AND REFERRAL

The advanced practice nurse shall consult with the collaborating physician by telecommunication or in person as needed.  In the absence of the designated collaborating physician, another physician shall be available for consultation.

The advanced practice nurse shall inform each collaborating physician of all written collaborative agreements he or she has signed with other physicians, and provide a copy of these to any collaborating physician upon request.

4.

DELEGATION OF PRESCRIPTIVE AUTHORITY

As the collaborating physician, any  prescriptive authority delegated to the advanced practice nurse is set forth in Attachment C.

NOTE:  ADVANCED PRACTICE NURSE MAY ONLY PRESCRIBE CONTROLLED SUBSTANCES UPON RECEIPT OF AN ILLINOIS MID-LEVEL PRACTITIONER CONTROLLED SUBSTANCE LICENSE.

WE THE UNDERSIGNED AGREE TO THE TERMS AND CONDITIONS OF THIS WRITTEN COLLABORATIVE AGREEMENT.

Collaborating Physician

Signature/Date

Advanced Practice Nurse

Signature/Date

(Physician's Typed Name)

(Advanced Practice Nurse's Typed Name)