Collaboration Agreement No:
7918
Confirmation No:
7918_3623C0005441
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Private Practice / Outpatient Clinic
Address
10 West Market Street Suite 2900
Indianapolis
IN 46204
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: 508 Idlewild Avenue Suite 5, Easton MD 21601
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. Susan Kaufman Arnoult | License No: D0060171