Section 1400.EXHIBIT A   Sample Written Collaborative Agreement

PRESCRIBING PSYCHOLOGIST

WRITTEN COLLABORATIVE AGREEMENT

A.        PRESCRIBING PSYCHOLOGIST INFORMATION

5.         ATTACHMENTS (If applicable):

Copies of Clinical and Prescribing Psychologist Licenses

Copy of Certificate of Insurance

Copies of other written collaborative agreements (if any)

B.        COLLABORATING PHYSICIAN

6.         PRACTICE SITES:  (Attach List of Sites)

C.        PRESCRIBING PSYCHOLOGIST COLLABORATING PHYSICIAN WORKING RELATIONSHIP

1.         WRITTEN COLLABORATIVE AGREEMENT REQUIREMENT

A written collaborative agreement is required for all prescribing psychologists practicing under a prescribing psychologist license.

The collaborating physician shall file with the Illinois Department of Financial and Professional Regulation (the "Department") notice of delegation of prescriptive authority and any termination of delegation.  In addition, a copy of a fully executed collaborative agreement shall be available to the Department within a reasonable time upon request to either the prescribing psychologist or the collaborating physician.  The prescribing psychologist shall inform the collaborating physician of all active collaborating agreements he/she has signed and provide the collaborating physician copies of all those collaborating agreements.  The collaborating physician shall not enter into more than 3 collaborating agreements with prescribing psychologists at the same time.

2.         SCOPE OF PRACTICE

Under this agreement, the prescribing psychologist will work in an active practice to deliver mental health care services to patients.  This includes, but is not limited to, assessment and diagnosis, ordering diagnostic and therapeutic tests and procedures, ordering imagery, interpreting and using the results of diagnostic and therapeutic tests and procedures ordered by the prescribing psychologist or another health care professional and prescriptive authority.  The prescribing psychologist will consult with the collaborating physician as outlined in Section 3 below.

3.         COLLABORATION AND CONSULTATION

Collaboration and consultation shall be adequate if the collaborating physician:

(A)       participates in the joint formulation and joint approval of orders or guidelines with the prescribing psychologist and periodically reviews those orders and the services provided patients under those orders in accordance with accepted standards of medical practice and prescribing psychologist practice;

(B)       meets in person or in real-time video conferencing with the prescribing psychologist at least once a month to provide collaboration and consultation for review of safety and quality clinical care or treatment;

(C)       is available through telecommunications for consultation on medical problems, complications and emergencies or for patient referral; and

(D)       reviews medication orders of the prescribing psychologist no less than monthly, including review of laboratory tests and other tests as available.

Nothing in this agreement shall be construed to limit the authority of a prescribing psychologist to perform all duties authorized under the Clinical Psychologist Licensing Act.

The written collaborative agreement shall be for medications for the treatment of mental health disease or illness the collaborating physician generally provides to his or her patients in the normal course of clinical practice, with the exception of the following:

(A)       Patients who are less than 17 years of age or patients who are over 65 years of age.  If a patient is 65 years of age, the prescribing psychologist shall begin transferring care to a physician at least 3 months prior to the patient's 66^th birthday.

(B)       Patients who have disclosed they are pregnant, or who the prescribing psychologist otherwise discovers are pregnant.

(C)       Patients who have disclosed serious medical conditions, such as heart disease, cancer, stroke or acute seizures, and patients with developmental and intellectual disabilities.  If there is a question as to whether a patient has disclosed a medical condition that should be considered serious, and thus prevent the prescribing psychologist from prescribing medication, then the prescribing psychologist should consult with the collaborating physician, who will determine whether the patient's condition should be considered a serious medical condition.

(D)       Prescriptive authority for benzodiazepine Schedule III controlled substances.

(E)       Prescriptive authority for any controlled substance to be delivered by injection.

(F)       Prescriptive authority for any Schedule II substance.

(G)       Prescriptive authority for any narcotic drug as defined by Section 102 of the Illinois Controlled Substances Act.

4.         COMMUNICATION, CONSULTATION AND REFERRAL

The prescribing psychologist shall consult with the collaborating physician by telecommunication, real-time video conferencing or in person, as needed. In the absence of the designated collaborating physician, another physician shall be available for consultation, as designated by agreement between the collaborating physician and prescribing psychologist.

5.         DELEGATION OF PRESCRIPTIVE AUTHORITY

As the collaborating physician, any prescriptive authority delegated to the prescribing psychologist is set forth in an attached document.  As required by 225 ILCS 15/4.3(d)(1), any delegation of a Schedule III through V controlled substance shall identify the specific controlled substance by brand name or generic name.

Should the collaborating physician or prescribing psychologist wish to terminate this agreement, he/she should provide at least 30 days written notice to the other practitioner so that the prescribing psychologist has the opportunity to enter into a collaborating agreement with another qualified physician.  If either practitioner has a change in his/her status that affects his/her ability to participate in this agreement, he/she must notify the other practitioner as soon as reasonably possible. This agreement may be terminated by either party immediately, without notice, for just cause. "Just cause" is defined as acts or omissions by the other practitioner that would be grounds for discipline of a license issued under the Medical Practice Act or the Clinical Psychology Licensing Act.

NOTE: THE PRESCRIBING PSYCHOLOGIST MAY ONLY PRESCRIBE CONTROLLED SUBSTANCES UPON RECEIPT OF AN ILLINOIS MID-LEVEL PRACTITIONER CONTROLLED SUBSTANCES LICENSE.

WE THE UNDERSIGNED AGREE TO THE TERMS AND CONDITIONS OF THIS WRITTEN COLLABORATIVE AGREEMENT.