North Carolina Board of Nursing

Nursing Practice

Nurse Practitioner

Back-up Supervising Physician

No specific form is required to list or add back-up supervising physicians.  An on-going list of back-up supervising physicians approved by your primary supervising physician, signed and dated by each back-up supervising physician, the primary supervising physician, and the nurse practitioner, must be retained as described in 21 NCAC 36 .0801 (2) and Rule 21 NCAC 32M .0101 (2).  Please do not send the documents to the Boards, but retain those documents for five (5) years.

Sample form for back-up supervising physicians