AHP II Change of Physician Sponsor
Please download the Application for Change of Practice and Sponsor which must be completed and returned to the Medical Staff Office for processing prior to beginning work with the new sponsor. Applicants will be permitted to work under the new sponsor only after the following items are received and the application is approved by the Credentials Committee:
Completed application signed by the AHP practitioner and the sponsoring physician;
Evidence of new malpractice insurance coverage (minimum amounts of $1m/3m);
Scope of practice attestation form (see links below and select appropriate form) signed by the AHP practitioner and sponsoring physician;
For nurse practitioners/physician assistants only, verification must be obtained from the NC Medical Board authorizing the applicant to work as a NP/PA with the new sponsor. Please submit a copy of the Statement of Approval Letter from the NC Medical Board.
Scope of Practice Forms
Nurse Practitioner/Physician Assistant
Nurse Midwife
Licensed Professional Counselor
RNFA, Rounding Nurse Scrub Tech, OR Nurse, Dental Tech, Medical Assistant, Vascular Sonographer Tech
Audiologist
Perfusionist
Psychologists, Master's Level
Social Worker
