Collaboration Agreement No:
4270
Confirmation No:
4270_2130C0003422
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Facility
University Of Md Upper Chesapeake Medical Center
Address
500 Upper Chesapeake Drive
Bel Air
MD 21014
Is this the location where a copy of your collaboration agreement is on file? NO
A copy (paper or electronic) must be immediately available upon request by the Board.
Location: 10200 Grand Central Avenue, Suite 220, Owings Mills, MD 21117
Section 3 - Advanced Duties and Prescriptive and Dispensing Authority
1.Does this Collaboration Agreement include Advanced Duties?
YES
1a. Advanced Duties:
Please select the best option.
I attest that I:
Note:
(Exempt locations include hospitals, ambulatory surgical facilites, FQHC, or another practice setting listed on a hospital delineation of privileges.)
2. Does this Collaboration Agreement include prescriptive authority?
YES
3. Does this Collaboration Agreement include dispensing authority under a physician's active dispensing permit?
YES
Physician's Name: Dr. Brad Douglas Lerner | License No: D0034608