(a)

1. (1) This delegation agreement is to be completed and signed by the physician assistant and his or her designated supervising physician.
2. (2) Said delegation agreement will be written in the form issued by the Arkansas State Medical Board.
3. (3) Said delegation agreement must be accepted by the board prior to licensure of the physician assistant.

(b) The delegation agreement as completed by the physician assistant and the supervising physician will include the following:

1. (1) Area or type of practice;
2. (2) Location of practice;
3. (3) Geographic range of supervising physician;
4. (4) The type and frequency of supervision by the supervising physician;
5. (5) The process of evaluation by the supervising physician;
6. (6) The name of the supervising physician;
7. (7) The qualifications of the supervising physician in the area or type of practice that the physician assistant will be functioning in;
8. (8) The type of drug prescribing authorization delegated to the physician assistant by the supervising physician; and
9. (9) The name of the back-up supervising physician or physicians and a description of when the back-up supervising physician or physicians will be utilized.