1. (1) A physician may enter into collaborative agreements with certified registered nurse practitioners not exceeding a cumulative three hundred and sixty (360) hours (nine FTEs) per week. The physician shall not collaborate with or supervise any combination of certified registered nurse practitioners, certified nurse midwives and/or assistants to physicians exceeding three hundred and sixty (360) hours per week (nine full-time equivalent positions). "One full- time equivalent" (FTE) is herein described as a person/persons collectively working forty hours a week, excluding time on call.

   1. (a) A physician collaborating with more than four FTEs per week shall engage in documented quality assurance review with each CRNP every month for six (6) months following the commencement of a collaborative practice with a new CRNP.
   2. (b) A physician shall disclose to the Board of Medical Examiners the existence of all collaborative and supervisory agreements to which the physician is a party, including collaborative and supervisory agreements in other states, and shall not be eligible to collaborate with or supervise any combination of certified registered nurse practitioners, certified nurse midwives and/or assistants to physicians exceeding three hundred and sixty (360) hours per week (nine full-time equivalent positions), inclusive of collaborative and supervisory agreements existing in other states. Agreements with an individual certified registered nurse practitioner, certified nurse midwife, and/or assistant to physician in multiple states shall only be counted once for purposes of calculating the total number of full-time equivalent positions
2. (2) Employees of the Alabama Department of Public Health and county health departments are specifically exempt from the requirements of paragraph (1) of this rule.
3. (3) CRNPs practicing under approved limited protocols, specified and approved by the Board of Nursing and the Board of Medical Examiners, may be specifically exempt from the FTE requirements of this rule, or as specified in the limited protocol, as determined by the Board of Nursing and the Board of Medical Examiners.

4. (4) A physician in collaborative practice may request approval from the Joint Committee for additional full-time certified registered nurse practitioner positions, with consideration given to the following factors, to ensure that an acceptable standard of care is rendered:

   1. (a) availability of the physician
   2. (b) practice settings and staffing needs for extended hours of service
   3. (c) risk to patients
   4. (d) educational preparation, specialty and experience of the parties in the collaborative practice
   5. (e) complexity and risk of procedures to be performed.
5. (5) Any certified registered nurse practitioners engaged in practice with a collaborating physician prior to the effective date of this rule, may not be denied approval for continued collaborative practice with that physician based on the ratio established in this rule.
6. (6) A physician in collaboration with CRNP, CNM or supervising Physician Assistant personnel totaling 360 hours per week (nine (9) FTEs) may request a transitional allowance increasing the total weekly hours for the purpose of orientation of the incoming CRNP. The transitional allowance shall not exceed 45 days. The physician shall request the transitional allowance in writing and specify the starting date for this FTE allowance.

Author: Alabama Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §§34-21-87, 34-24-53.

History: New Rule: Filed June 20, 1996; effective July 26, 1996. Amended: Filed August 25, 2003; effective September 29, 2003. Amended: Filed July 22, 2005; effective August 26, 2005. Amended: Filed July 2, 2015; effective August 6, 2015. Amended: Filed September 20, 2018; effective November 4, 2018. Amended: Filed August 23, 2019; effective October 7, 2019. Amended: Published April 30, 2021; effective June 14, 2021.