Physician Assistant Site Visit Form
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2PHYSICIAN ASSISTANT SITE VISIT FORM
{In accordance with Subchapter 32S–Physician Assistant Regulations 21 NCAC 32S.0201-.0223}
GENERAL INFORMATION:
Physician Assistant’s Name: ___________________________________Date of Visit:_______________
Date PA notified of visit:__/__/___ Start Time:____________
End Time:________________
Location of Audit/Interview: ________________________________________________________
Work Address: ___________________________________ ____ Work Phone #: __________________
____________________________________ Ext.#: ___________
MANDATORY NOTIFICATION OF INTENT TO PRACTICE:
[Section .0203]
Date PA submitted notification of Intent to Practice: ___/___/___
(Verified by investigator prior to conducting site visit: date verified: _____/_____/_____
IDENTIFICATION REQUIREMENTS
[Section .0210 & .0218(a)(2)]
:
GS 90-640 is referenced in .0210; pertinent wording of this statute is as follows, “When providing health
care to a patient, a health care practitioner shall wear a badge or other form of identification displaying
in readily visible type the individual's name and the license, certification, or registration held by the
practitioner. The badge or other form of identification is not required to be worn if the patient is being
seen in the health care practitioner’s office and, the name and license of the practitioner can be readily
determined by the patient from a posted license, a sign in the office, a brochure provided to patients, or
otherwise.”
License Number #: [Section .0210] __________
Annual Registration Certificate: [Section .0204 & .0210] Available for inspection: Yes ___ No____
Appropriate name tag: Yes _____ No _____ (.0218(a)(2) allows abbreviations, “PA or “PA-C”)
Other methods of identification at practice site(s): __________________________________________
PRESCRIPTIVE AUTHORITY
[Section .0212]
:
Dispensing (other than samples) from site(s): Yes __ No__
If yes, Pharmacy Permit #:______________________ Available for Inspection: Yes _____ No ______
Consulting Pharmacist’s name and license #: ___________________________________________
Prescription Blank* attached: Yes ___ No ______ Required to include the following:
PA’s name, address & practice telephone number [.0212 (5) (a)]?
Yes ___ No ___
PA’s license and DEA #’s [.0212 (5) (b)]?
Yes ___ No ___
Supervising MD’s name & telephone number [.0212 (5) (c)]?
Yes ___No ___
* Some large institutions have prescription pads with the practitioners’ names listed but without each
practitioner’s license and DEA numbers typed on them. In this situation, the PA should provide a
copy of a prior prescription that he or she has written.
Written instructions for prescribing drugs and written policy for periodic review:
Yes___ No____
[.0212 (2) & .0213 (c)]
SUPERVISORY/SCOPE OF PRACTICE STATEMENT: [Section .0213]
Signed Statement of Supervisory Arrangements:
Yes _____ No _____
(Required to be available for inspection [Sections .0201 (9) & .0213 (b) & (c)])
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