Instructions for Change or Addition of Supervising Physician

Change and Addition of Supervising Physician Application

Documents Required

The Physician Assistant and the Supervising Physician must complete, date and sign the application and return it to the Professional Licensing Agency along with the items listed below:
Application Fee - The fee for the change and addition application is $50.00.  Please make all checks payable to the Professional Licensing Agency. 

Supervisory Agreement - The supervising physician shall submit a description of the exact privileges and tasks the physician assistant shall be performing under the physician’s supervision.  The supervising agreement shall be specific to the physician assistant being hired “i.e. John Brown, PA will be responsible for…”  In addition give a detailed description of the process maintained for evaluation of the physician assistant’s performance. Also include a description of procedures for dealing with emergencies.  The supervising agreement must be completely typed, on letterhead, and signed by both the physician and physician assistant. The agreement must be submitted with the original signatures and dates of the Physician Assistant and the Supervising Assistant. Scanned or faxed agreements will not be accepted. The agreement must also indicate all locations where the PA and the supervising physician may practice.  Agreements also need to include a description of protocols used in the practice.  Protocols to be used for physician assistant prescribing may include clinical practice guidelines, reference texts, or other sources.

Please see the "supervisory agreement sample", located in the Application and Instructions for Physician Assistant section, for format and content questions.

A supervising physician may enter into agreements with more than 4 physician assistants, but may not supervise more than 4 at the same time.

If the physician assistant is applying for prescriptive authority in conjunction with this initial application, the supervising agreement must also include a list of drug schedules or classifications the physician assistant is delegated to prescribe. *As of July 1st, 2016, a list of medications, other than drug schedules, that the Physician Assistant will be prescribing is NO LONGER REQUIRED in the agreement.* The agreement must state whether the Physician Assistant will be only prescribing non-controlled substances, or will also be prescribing Schedule II through Schedule V drugs.

If you have not secured employment, you will not need to submit a supervising agreement.  Once you obtain employment, you will need to complete a change/addition application and submit it with the fee and a supervising agreement.