Verification of Supervision/Employment
New Jersey Office of the Attorney General
Division of Consumer Affairs State Board of Medical Examiners Physician Assistant Advisory Committee 140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625 Tel.: (609) 826-7100 Fax: (609) 777-0956
Verification of Supervision/Employment
Note: Please print information on this form.
As of__________________, _____________________________________, License #25 MP______________
Date
Physician Assistant
will be engaging in practice as a Physician Assistant under my direct Supervision.
________________________________________________________________________________________
Print name of Supervising Physician
Field of Practice
N.J. Physician License Number
_______________________________
Name of Practice/Facility
Facility type (circle one): Inpatient or Outpatient
______________________________
Telephone number (include area code)
________________________________________________________________________________________
Street address
City
State
ZIP code
________________________________________________________________________________________
Employer (if different from above)
________________________________________________________________________________________
Street address
City
State
ZIP code
In my absence, a plenary licensed Physician Designee will provide supervision.
Supervising Physician's Affidavit
I, the supervising physician, have read the statute, N.J.S.A. 45:9-27.10 et seq., and accept the responsibility for its implementation, and I certify that the forgoing statements made by me are true. I am aware that if any of the statements made by me are willfully false, I am subject to disciplinary action.
I also verify that I am a plenary licensed physician in the State of New Jersey and that my license is in good standing.
___________________________ ________________________________ ________________________
Print Supervising Physician's name
Signature of Supervising Physician
Date
___________________________ ________________________________ ________________________
Print Employer's name
Signature of Employer
Date
___________________________ ________________________________ ________________________
Print Physician Assistant's name
Signature of Physician Assistant
Date
................
................
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