MBP PA Collaboration Agreement

MARYLAND BOARD OF PHYSICIANS

Collaboration Agreement Receipt of Completion

PA License Number: C0008966 CHARLOTTE MARIE SMITH

Collaboration Agreement No:

3703

Submit Date:

2/14/2025

Confirmation No:

3703_1736C0008966

Section 1 - Physician Assistant Information
Confidential Information redacted.

Section 2 - Primary Practice Setting & Location:

Practice Type:

Hospital

Facility

Adventist Healthcare Shady Grove Medical Center

Address

9901 Medical Center Drive
Rockville MD 20850

County

Montgomery

Includes Telehealth?

Is this the location where a copy of your collaboration agreement is on file? YES
A copy (paper or electronic) must be immediately available upon request by the Board.

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:

have 7,000 hours OR;

work at an exempt location OR;

have a Board-approved advanced duty addendum on file or;

am training on advanced duties and will submit an advanced duty addendum to the Board for approval in the future.

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? NO

Maryland Board of Physicians 4201 Patterson Avenue Baltimore, MD 21215 410.764.4777 | Toll Free 800.492.6836