Nurse Practitioner Collaborative Agreement by akp25756

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                                      PARTIES DEFINED

This Agreement is entered into in the County of [ city name ], State of [ name ], between
______________, MD/DO (hereinafter "Physician") and _____________, NP and is effective as
of [ June 1, 20 ].


A. Physician agrees to be N.P.’s [ collaborating or supervising ] physician.

B. Nurse practitioner will own and operate an outpatient service, as described at [ ].

C. Physician will be available in accordance to the requirements set forth by the California
   Board of Registered Nursing, as described in the attached [California Practice Agreement
   and Standardized Procedures or Practice Protocol] (see Appendix A).

D. The N.P. and physician agree to the following collaborative practice agreement for
   the provision of health care services as described at [ ].

                              DESCRIPTION OF AGREEMENT

Physician agrees to participate in the following manner:

A. Review and approve the [California Practice Agreement and Standardized Procedures or
   Practice Protocol] (see Appendix A).


A. All new patients will be informed about physician medical services as described at [ ] and will list physician on the homepage of

B. Compensation to physician will not be contingent on receiving physician referrals, additional
   duties, patient payment, or insurance reimbursement.

C. Physician will not be obligated or expected to recruit or refer patients to the nurse

D. Nurse practitioner will provide physician will appropriate tax forms at the end of the year.

E. Nurse practitioner will pay $250.00 for 32 hours per month of office space and consultation.
   Payment will be according to actual use of office space. The monthly fee will be divided by
   actual hours of office use.
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                                RELATIONSHIP OF PARTIES

The parties intend that a physician and nurse practitioner working agreement will be created by
this agreement.

A. Nurse practitioner agrees to practice in adherence to the attached [ your state ] practice
   agreement and [ standardized procedures or process protocol ] (Appendix A).

B. Nurse practitioner is responsible for contacting and informing the physician and/or
   community psychiatrist about patient concerns, in accordance to the [your state ] practice
   agreement and standardized procedures.

C. Nurse practitioner recognizes and accepts responsibility for contacting the physician and/or
   community psychiatrist in a timely manner about any patient concerns or as indicated by the
   California practice agreement and standardized procedures.

D. Patients will be informed about the physician’s role relative to their care.

E. Nurse practitioner acknowledges that the physician may or may not express his/her
   preference, at any given time, to be directly involved in the care of any particular patient.
   Physician may take over the care of any given patient/client at any time.

F. Physician is not to be considered an agent or employee of the nurse practitioner for any

G. Any employees of the nurse practitioner are not entitled to any of the benefits that the
   physician provides for her employees.

H. It is understood that the physician does not agree to work with the nurse practitioner

I. It is further understood that the physician is free to contract with other professionals to
   provide similar or the same services.

J. It is hereby agreed that the nurse practitioner, by virtue of the working relationship with the
   physician, will render healthcare services as described on the following website:
   [ ]. The nurse practitioner will be responsible for managing all aspects of
   patient care, including collecting fees, scheduling patients/clients, and maintaining


A. Each party is responsible for determining their own malpractice insurance needs.

B. Nurse practitioner will pay for the physician malpractice insurance cost for vicarious
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A. Either party may cancel this agreement with a 30-day written notice; otherwise, the
   agreement shall remain active on a month to month basis.

B. Upon termination of agreement, both parties agree that there will be no future restrictions for
   any length of time that affects their respective ability to practice or manage patients in any
   capacity at any location.

C. Upon termination of agreement by either party, effective immediately, there will be
   absolutely no restrictions in terms of either party recruiting patients or ability to practice in
   the same area.

D. While specifics restrictions may not always be identified ahead of time, both parties agree
   that termination of this agreement should in no way create any future practice restrictions for
   either party.

E. The agreement will be considered active upon the completion of the following conditions:

   1) This nurse practitioner and physician practice agreement is signed by both physician and
      nurse practitioner.

   2) California practice agreement and standardized procedures are signed by both the nurse
      practitioner and physician.

   3) This Agreement constitutes the complete and final expression of the agreement of the
      parties and is intended as a complete and exclusive statement of the terms of their
      agreements, and supersedes all prior and contemporaneous offers, promises,
      representations, negotiations, discussions, communications, and agreements that may
      have been made in connection with the subject matter of this Agreement.

   4) This Agreement may only be amended by a subsequent written agreement executed by
      the parties


SIGNATURE______________________________________                          DATE_________________
[ Your name here ], NP

SIGNATURE______________________________________                          DATE_________________
[ Physician Name ], DO/MD

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