N.J. Admin. Code Tit. 13, ch. 39, subch. 13, app APPENDIX - APPENDIX

Collaborative Practice Agreement

The Pharmacist(s) and Physician(s) listed below are parties to this collaborative practice agreement, through which the pharmacist(s) receives authority, under the supervision of the physician(s) (or covering physician), to perform the functions outlined in accordance with applicable New Jersey statutes and regulations.

Physician:

Name: ____________________ Title:

Address:

Phone Number: ___________ License Number:

Type of Practice/Specialty:

Pharmacist:

Name:

Address:

Phone Number: ____________ License Number:

Qualifications for Collaborative Practice:

Describe the functions and responsibilities, including scope and authority, to be exercised by the pharmacist (attach extra sheets if needed):

Indicate any restrictions placed on the use of certain types or classes of drugs or drug therapies under this agreement (attach extra sheets if needed):

Indicate any diagnosis, or types of diseases which are specifically included or excluded under this agreement (attach extra sheets if needed):

Attach any protocols to be used in decision making or other activities contemplated under this agreement. This must include a protocol for treating an acute allergic or other adverse reaction related to drug therapy. Each protocol must establish when physician notification is required, the time frame within which the pharmacist must notify the physician of any change in dose, duration or frequency of medication prescribed, and the type of pharmacist documentation required. Written notification, by either facsimile or electronic means, shall be provided to the physician no later than eight hours after any change in prescribed medication is made by the pharmacist.

Physician Signature: _____________ Date:

Pharmacist Signature: _____________ Date:

Notes

N.J. Admin. Code Tit. 13, ch. 39, subch. 13, app APPENDIX