Collaboration Agreement No:
9597
Confirmation No:
9597_4887C0006268
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Private Practice / Outpatient Clinic
Facility
Express Medical Care, LLC dba Revive Medical Wellness & Aesthetics
Address
1185 Mount Aetna Rd STE200
Hagerstown
MD 21740
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:
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