Board of Medicine
ARNP / EMT / Paramedic Protocol Form
S. 458.348(1)(a), Florida Statutes, states in part, when a physician enters into an established protocol with an Advanced Registered Nurse Practitioner, an Emergency Medical Tech (EMT) or a Paramedic which protocol contemplates the performance of medical acts identified and approved by the joint committee pursuant to s. 464.003(3)(c) or acts set forth in s. 464.012(3) and (4), the physician shall submit notice to the board. The notice shall contain a statement in substantially the following form.
I,__,
(Please type or print name of physician)
license number ME00_______________of
__________________________________________________________________
(Please type or print practice location)
have hereby 
entered into a established protocol with
be filed within 30
(amount of)
terminated my formal supervisor relationship, standing orders, or an _ARNP(s), EMT(s), Paramedic(s). S. 458.348(1)(b), F.S. Notice shall
days of entering into the relationship, orders, or protocol. Notice also shall be provided within 30 days after the physician has terminated any such relationship, orders, or protocol.
|
__________ |
(Print or Type Name of ARNP/EMT/Paramedic) |
|
(Print or Type Name of ARNP/EMT/Paramedic) |
___________________________ |
___________________________ |
(License Number) |
(License Number) |
|
___________________________ |
(Effective Date) |
(Effective Date) |
__________________________________________________________________
(Signature of Physician)
Complete this form and return it to: Department of Health, Board of Medicine, 4052 Bald Cypress Way, BIN #C-03, Tallahassee, FL 32399-3253, or fax it to 850-488-0596. No additional documentation required. The protocol form must be filed with the Department within thirty (30) days of renewal of the ARNP’s license and any change to the protocol.
NOTE: Only one physician per form. Use extra sheets for additional ARNP’s / EMT’s / Paramedics.
DH-MQA1069 Rule 64B8-35.002 03/2003 Revised 6/2013
