N.D. Admin. Code tit. 61, art. 61-04, ch. 61-04-08, app COLLABORATIVE AGREEMENT FORM
The pharmacists and practitioners listed below are parties to this collaborative agreement, through which the pharmacist receives limited prescriptive authority under the supervision of the practitioner in accordance with North Dakota Century Code section 43-15-31.4 and administrative rules.
[Please review the administrative rules governing collaborative agreements which accompany this form before proceeding.]
1. Describe the scope and authority to be exercised by the pharmacist. (If requesting authority to initiate drug therapy, pharmacist must include credential verification.)
2. Indicate any restrictions placed on the use of certain types or classes of drugs or drug therapies under this agreement. (Note: Schedule II drugs are excluded by these rules.)
3. If appropriate, indicate any diagnoses which are specifically included or excluded under this agreement.
4. Attach any protocols or guidelines to be used in decisionmaking or other activities contemplated under this agreement. This must include a protocol for treating acute allergic or other adverse reactions related to drug therapy.
5. Describe approved situations, if any, in which the notification time limit may be extended beyond twenty-four hours (not to exceed seventy-two hours). Attach additional sheets if necessary.
N.D. Admin Code tit. 61, art. 61-04, ch. 61-04-08, app COLLABORATIVE AGREEMENT FORM