Ill. Admin. Code tit. 68, pt. 1300, subpt. E, exh. A - Sample Written Collaborative Agreement

ADVANCED PRACTICE REGISTERED NURSING

WRITTEN COLLABORATIVE AGREEMENT

A. ADVANCED PRACTICE REGISTERED NURSE INFORMATION

1. NAME: ______________________________________________________

2. ILLINOIS RN LICENSE NUMBER: _________________________________

ILLINOIS APRN LICENSE NUMBER: __________________________________

ILLINOIS CONTROLLED SUBSTANCES 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: (Attach List of Sites)

8. CONTACT NUMBER: ___________________________________________

FACSIMILE NUMBER:______________________________________________

EMERGENCY NUMBER: ____________________________________________

9. ATTACHMENTS:

Copy of Certification/Recertification

Copies of RN & APRN License

Copy of Certificate of Insurance

Copy of Controlled Substances License

B. COLLABORATING PHYSICIAN/PODIATRIC PHYSICIAN/DENTIST INFORMATION

1. NAME: ______________________________________________________

2. ILLINOIS MEDICAL LICENSE NUMBER: ____________________________

3. PRACTICE AREA OR CONCENTRATION: ___________________________

4. BOARD CERTIFICATION (if any): __________________________________

5. CERTIFYING ORGANIZATION: ____________________________________

6. PRACTICE SITES: (Attach List of Sites)

7. CONTACT NUMBER: ___________________________________________

FAX NUMBER: ____________________________________________________

EMERGENCY NUMBER: ____________________________________________

C. ADVANCED PRACTICE REGISTERED NURSE COLLABORATING PHYSICIAN/ PODIATRIC PHYSICIAN/DENTIST WORKING RELATIONSHIP

1. WRITTEN COLLABORATIVE AGREEMENT REQUIREMENT

A written collaborative agreement is required for all Advanced Practice Registered Nurses (APRNs) engaged in clinical practice outside of a hospital, hospital affiliate, or ambulatory surgical treatment center (ASTC) except for those APRNs granted full practice authority. An APRN may provide services in a licensed hospital, hospital affiliate, or ASTC without a written collaborative agreement or delegated prescriptive authority.

2. SCOPE OF PRACTICE

Under this agreement, the APRN will collaborate with the collaborating physician, dentist or podiatric physician in an active practice to deliver health care services. This agreement includes, but is not limited to, advanced nursing patient assessment and diagnosis, ordering diagnostic and therapeutic tests and procedures, performing those tests and procedures when using health care equipment, interpreting and using the results of diagnostic and therapeutic tests and procedures ordered by the APRN or another health care professional, ordering treatments, ordering or applying appropriate medical devices, using nursing, medical, therapeutic and corrective measures to treat illness and improve health status, providing palliative and end-of-life care, providing advanced counseling, patient education, health education and patient advocacy, prescriptive authority, and delegating nursing activities or tasks to a LPN, RN or other personnel.

If applicable, the APRN shall maintain privileges at the following hospitals for the designated services:

Hospitals: ________________________________________________________

A copy of this written collaborative agreement shall remain on file at all sites where the APRN renders service and shall be provided to the Illinois Department of Financial and Professional Regulation upon request.

3. COLLABORATION AND CONSULTATION

(A) Collaboration and consultation between a certified nurse midwife, certified nurse practitioner, or certified nurse specialist and the collaborating physician includes the following:

(i) The APRN seeking the advice or opinion of the collaborating physician through the mutually agreeable methods of communication, which may be in person or through telecommunications or electronic communications (see 225 ILCS 60/54.5(b)(3) and 225 ILCS 65/65-35(b));

(ii) Discussing the condition of any patients for whom a controlled substance has been prescribed under delegated prescriptive authority at least once a month for Schedule II controlled substances (see 225 ILCS 65/65-40(b) and (d)(4)); and

(iii) The APRN informing each collaborating physician of all written collaborative agreements he or she has signed with other physicians and providing a copy of these to any collaborating physician, upon request.

(B) Collaboration and consultation between a certified registered nurse anesthetist (CRNA) and the collaborating physician, dentist or podiatric physician includes the following:

(i) A licensed CRNA may provide anesthesia services pursuant to the order of a licensed physician, podiatric physician or dentist.

(ii) For anesthesia services, an anesthesiologist, physician, podiatric physician or dentist 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.

(iii) A CRNA may select, order and administer medications, including controlled substances, and apply appropriate medical devices for delivery of anesthesia services under the anesthesia plan agreed to by an anesthesiologist, or the operating physician, operating podiatric physician or operating dentist. (See 225 ILCS 65/65-35 (c-5) and (c-10).)

(iv) In a physician's office, the CRNA may only provide anesthesia services if the physician has training and experience in the delivery of anesthesia services to patients.

(v) In a podiatric physician's office, the CRNA may only provide those services the podiatric physician is authorized to provide pursuant to the Podiatric Medical Practice Act.

(vi) A collaborative agreement between a CRNA and a dentist must be in accordance with 225 ILCS 65/65-35 (c-10). In a dentist's office, the CRNA may only provide those services the dentist is authorized to provide pursuant to the Illinois Dental Practice Act.

4. DELEGATION OF PRESCRIPTIVE AUTHORITY

As the collaborating physician/podiatric physician, any prescriptive authority delegated to the APRN is set forth in an attached document, which must be filed with the Department of Financial and Professional Regulation and the Department of Human Services Prescription Monitoring Program.

NOTE: ADVANCED PRACTICE REGISTERED NURSES MAY ONLY PRESCRIBE CONTROLLED SUBSTANCES UPON RECEIPT OF A FEDERAL DEA REGISTRATION AND AN ILLINOIS MID-LEVEL PRACTITIONER CONTROLLED SUBSTANCES LICENSE. (See 225 ILCS 65/65-40(a) and 68 Ill. Adm. Code 1300.430(c).)

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

________________________	________________________
Collaborating Physician/Podiatric Physician /Dentist Signature/Date	Advanced Practice Registered Nurse Signature/Date
________________________	________________________
(Physician's/Podiatric Physician's /Dentist's Typed Name)	(Advanced Practice Registered Nurse's Typed Name)

Notes

Ill. Admin. Code tit. 68, pt. 1300, subpt. E, exh. A

Amended at 43 Ill. Reg. 6924, effective 6/14/2019