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Part 1 (completed by PA)

Some data elements are hidden for confidentiality.

Application ID:  20206
MBP Delegation Agreement ID:  23087
PA License Number:  C0006041
PA Name:  Wanda Lumpkins
Date Submitted to PSP: 11/11/2021
Date Completed by PSP: 11/11/2021

1a. Physician Assistant Information

Address and Contact Information:
(Confidential)

1b. Primary Supervising Physician Information

PSP License No:  D0075094
PSP Name:  Rafai Asghar Bukhari

Public Address:
21044 Frederick Road
GERMANTOWN MD 20876

Contact:
Phone: n/a
Fax: n/a

2. E-mail Addresses for Board Correspondence

PA Email:  xxxxxxxxxxxxxxx
PSP Email:  xxxxxxxxxxxxxxx

3. Practice Setting

Check all settings in which the PA will practice

4. Telehealth

I intend to practice medicine through telehealth, and I will be physically located in Maryland.

5. Practice Setting Locations

List the location for each practice setting identified in Section 3.

Number of Locations: 0
PSP has not reported location setting information.

6. Delegated Medical Acts


(The PSP will also attest on his/her portion of the online delegation agreement.)

Prescriptive and Dispensing Authority

  1. I have passed the physician assistant national certification exam administered by the National Commission on the Certification of Physician Assistants (NCCPA) within the previous 2 years or have successfully completed 8 category 1 hours of pharmacology education within the previous 2 years.
  2. I have a bachelor's degree or its equivalent or have successfully completed 2 years of work experience as a physician assistant.
  3. All prescribing activities by the PA will comply with all federal and State laws governing the prescribing of medications, including controlled dangerous substances.
  4. All prescriptions written by the PA will include the PA's name and the PSP's name, business address, and business telephone number, legibly written or printed.
  5. PAs must obtain registrations with the Maryland Office of Controlled Substances Administration and the Drug Enforcement Administration before prescribing or dispensing controlled dangerous substances.
  6. I have reviewed the  Attestations that will be signed by the PSP in Part 2 of this Delegation Agreement.

Attestations for Access to the PSP, Release, and Affirmation


Access to Primary Supervising Physician
Release
Affirmation

Electronic Signature of Physician Assistant

Name: Wanda Lumpkins
Date: 11/11/2021

Receipt

Please note that your PSP needs to complete Part 2 of this agreement. You may not begin working until your PSP completes the delegation agreement. You may view the status of your delegation agreement in your Practitioner Profile on the Board's website.

The Board may disapprove any delegation agreement if:

  • The application does not meet the requirements of the law; or
  • The Board believes that the PA is unable to perform the delegated medical acts safely; or
  • The Board determines the application is incomplete.
The PSP and the PA will be contacted by email if additional information is required. Failure to provide the required information may result in disciplinary action.

Payment Date:  11/11/2021
Fee Paid:  $200.00
Transaction ID:  281752536

Part 2 (completed by PSP)

Some data elements are hidden for confidentiality.

Application ID:  20206
Date Submitted:  11/11/2021

1. Physician Assistant and Primary Supervising Physician Information

Physician Assistant
PA License No:  C0006041
PA Name:  Wanda Lumpkins

Primary Supervising Physician
PSP License No:  D0075094
Dr. Rafai Asghar Bukhari
21044 Frederick Road
GERMANTOWN MD 20876

This is the public address listed in your Practitioner Profile. Any address changes made after the delegation agreement was started will not affect this delegation agreement since Part 1 was already submitted by the Physician Assistant and included this address.

2. E-mail Addresses for Board Correspondence

PA Email:  xxxxxxxxxxxxxxxxxxxx
PSP Email:  xxxxxxxxxxxxxxxxxxxx

3. Delegated Medical Acts


(The PA will also attest on his/her portion of the online delegation agreement.)

4. Scope of Practice

Choose the appropriate scope of practice(s) of the PSP.

Other - urgent care & Primary Care (Primary_scope)

5. Quality Assurance

Describe the process by which you will review and evaluate the PA's practice, appropriate to the practice setting and consistent with current standards of acceptable medical practice.

All charts reviewed by Medical Director and/or full-time physician. Quality Assurance inspection by regional medical director and annual evaluations by medical director.

6. Supervision

Which of the following continuous physician supervision methods will be utilized in your practice?
Check all that apply.

7. Prescriptive Authority

Select all that apply.

m79206
10/31/2024

8a. Dispensing of Prescription Drugs

The PSP has an active drug dispensing permit issued by the Board.

8b. Dispensing of Prescription Drugs

Select all that apply.

3932
10/18/2023 2:47:00 PM

9a. Attestations for Prescriptive and Dispensing Authority

I Attest:
  1. All dispensing of prescription drugs, if applicable, will comply with all federal and State laws and the Board's regulations including, but not limited to, Health Occupations Article (H.O.), §§12-102 and 15-302.2, Annotated Code of Maryland, and COMAR 10.32.03 and 10.32.23.
  2. Medical charts or records will contain a notation of any prescriptions written or dispensed by the PA.
  3. The PSP has an active drug dispensing permit issued by the Board or is exempt from the permit requirement pursuant to H.O. §12-102(d) through (g).
  4. The PA will dispense prescription drugs only at locations where the PSP is authorized to dispense drugs.
  5. I will notify the Board within 5 business days if the PA's delegation to prescribe or dispense has been restricted or revoked.

Electronic Signature of PSP

Full Name: Rafai Asghar Bukhari
Date:  11/11/2021

9b. Attestation of Primary Supervising Physician

I Attest:
  • I have read and am thoroughly familiar with Health Occupations Article, Title 15, Annotated Code of Maryland, and COMAR 10.32.03, which govern PAs and the requirements and responsibilities of the PSP.
  • The PA will practice only within the scope of practice of the PSP or a designated ASP.
  • I assume responsibility for maintaining and enforcing mechanisms that assure this requirement is met on a continuous basis.
  • All medical acts to be delegated to the PA are within my scope of practice or the scope of practice of a designated ASP and are appropriate to the PA's education, training, and level of competence and will only include permitted medical acts in accordance with Health Occupations Article, §15-301(d)(1) - (7) and COMAR 10.32.03.07A(4).
  • The PA in this delegation agreement will only be performing core duties. Any advanced duties, including, but not limited to psychiatric duties, must be approved by the Board. (See Health Occupations Article, §15-302).
  • I accept responsibility for any care given by the named PA.
  • I will utilize the mechanisms of continuous supervision described in this delegation agreement.
  • I will respond in a timely manner when contacted by the PA.
  • I understand that failure to perform the supervision provided in the agreement constitutes unprofessional conduct in violation of Health Occupations Article, §14-404(a)(3)(ii), Annotated Code of Maryland.
  • I will report to the Board, within 5 days:
    • Any termination for any reason, including quality of care issues; and
    • Any limitation, reduction or change of the terms of employment of PA for any reasons that might be grounds for discipline under Health Occupations Article, §15-314.
  • I understand that the PA is my agent in the performance of all practice-related activities, including the oral, written, or electronic ordering of diagnostic, therapeutic, and other medical services.
  • I will not delegate medical acts under a delegation agreement to more than four PAs at any one time. (Applicable to PSPs in a setting other than a hospital, correctional facility, detention center, or public health facility).
  • I will not permit a PA to delegate the duties that I have delegated to the PA to another person.

9c. Attestations for Access to the PSP, Release, and Affirmation

 Access to Primary Supervising Physician
I attest that the PSP and the PA will establish a plan for the types of cases that require a physician plan of care or require that the patient initially or periodically be seen by the PSP and the patient will be provided access to the PSP on request.
 Release
I agree that the Maryland Board of Physicians (the Board) and the Physician Assistant Advisory Committee (PAAC) may request any information necessary to process this delegation agreement from any person or agency, including but not limited to former and current employers, government agencies, the National Practitioners Data Bank, hospitals, and other licensing bodies, and I agree that any person or agency may release to the Board the information requested. I also agree to sign any subsequent releases for information that may be requested by the Board.
 Affirmation
I solemnly affirm, under the penalties of perjury, that the contents of the foregoing document are true to the best of my knowledge, information, and belief.
 Collaboration with a Primary Supervising Physician
I understand that this application requires collaboration with a Primary Supervising Physician. I understand that the selected PSP must complete their portion of the delegation agreement application. I understand that failure to complete the 2-part application process within 60 days of receipt of payment will result in the closure of this delegation agreement application. I understand that fees are non-refundable.

Electronic Signature of PSP

Full Name:  Rafai Asghar Bukhari
Date:  11/11/2021

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