The active practice request form submitted by each physician assistant shall contain the following:

1. (a) The name and license number of the physician assistant;
2. (b) the name and license number of the supervising physician;
3. (c) the name and license number of each substitute supervising physician;

4. (d) information about each practice location, including hospitals and other facilities, which shall include the following:

   1. (1) The street address and telephone number;
   2. (2) a description of the type of medical services provided to patients;
   3. (3) specification of whether the location is a different practice location and, if so, whether the physician assistant has spent at least 80 hours since being licensed under the direct supervision of a physician licensed in this state; and
   4. (4) the name of each substitute supervising physician who shall provide supervision to the physician assistant at the practice location if the supervising physician is temporarily unavailable;

5. (e) the written agreement, which shall contain the following information:

   1. (1) A description of the medical services and procedures that the physician assistant may perform at each practice location;
   2. (2) a list of any medical services and procedures that the physician assistant is prohibited from performing;
   3. (3) any types of supervision required for specified medical services and procedures;
   4. (4) the prescription-only drugs, including controlled substances and professional samples, that the physician assistant is authorized to prescribe, administer, dispense, or distribute;
   5. (5) any specific exceptions to the physician assistant's authority to prescribe, administer, dispense, or distribute prescription-only drugs, including controlled substances and professional samples;
   6. (6) a description of the procedure for communication between the supervising physician and the physician assistant if the physician assistant is at a different practice location; and
   7. (7) a description of the procedure for notifying a substitute supervising physician if the supervising physician is unavailable;
6. (f) an acknowledgment that the supervising physician or a substitute supervising physician shall be available for communication with the physician assistant at all times during which the physician assistant could reasonably be expected to provide professional services;
7. (g) an acknowledgment that a current copy of the active practice request form shall be maintained at each practice location and that any amendments to the active practice request form shall be provided to the board within 10 days of being made;
8. (h) confirmation that the supervising physician has established and implemented a method for the initial, periodic, and annual evaluation of the professional competency of the physician assistant required by K.A.R. 100-28a-10;
9. (i) confirmation that the medical services and procedures that the physician assistant is authorized to perform are within the clinical competence and customary practice of the supervising physician and all substitute supervising physicians; and
10. (j) the dated signatures of the physician assistant, supervising physician, and all substitute supervising physicians.

(Authorized by and implementing K.S.A. 2015 Supp. 65-28a03 and 65-28a08; effective, T-100-2-13-01, Feb. 13, 2001; effective June 1, 2001; amended, T-100-12-10-15, Jan. 11, 2016; amended May 6, 2016.)