APPROVAL STATEMENT Clause Samples

APPROVAL STATEMENT. Having read and understood the full contents of this Agreement, the parties hereto agree to be bound by its terms. Primary Supervising Physician signature: ________________________Date:   Supervising MD typed name:   Advanced Practice Provider signature: __________________________Date:   APP typed name:   Name of Advanced Practice Provider:   Please keep a copy of this form on file at all practice sites for which it applies as part of the inspectable supervisory arrangements statement. Signature of Primary Supervising Physician: ___________________ Date:   Signature of Advanced Practice Provider: ­­­­­­­­­­­­­­­­­_____________________ Date:   Back-up supervising physician:   Date:   Back-up supervising physician:   Date:   Back-up supervising physician:   Date:   Back-up supervising physician:   Date:   Back-up supervising physician:   Date:   Back-up supervising physician:   Date:  

APPROVAL STATEMENT. Having read and understood the full contents of this Agreement, the parties hereto agree to be bound by its terms. Primary Supervising Physician signature: _ Date: Supervising Physician typed name: Advanced Practice Providersignature: Date: APP typed name: