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Form preview New jersey agreement form State of New Jersey Division of Taxation Form 906 CLOSING AGREEMENT REQUEST Enclosed packet includes A copy of the Closing Agreement statute. 1. The case shall not be reopened as to the matters agreed upon or the agreement modified by an officer employee or agent of the State of New Jersey and 2. There can be a series of agreements covering a single tax period. permanently closed or where the taxpayer shows sufficient reason for desiring a closing agreement and there would be no disadvantage to the State of New Jersey in entering into it. If the proposed agreement relates to a prior taxable period it must be submitted before a case with respect to the tax liability is filed in the Division of Tax Appeals or in any Division of the Superior Court of New Jersey or in any Federal Court. A Closing Agreement Form 906 to complete. Appointment of Taxpayer Representative if applicable. A Financial Statement of Debtor Section I through Section V to be completed. National Standard Expenses information to be used in the completion of Section II of Financial Statement of Debtor. NOTE Copies of the Taxpayer s last two years Individual IRS returns and Corporate returns if applicable are required to be submitted with Form 906. Send completed required information to New Jersey Division of Taxation 9th Floor PO Box 245 Trenton NJ 08695-0245 Authority Unless otherwise expressly noted all provisions of this chapter were adopted pursuant to authority of N.J.S.A. Chapter Table of Contents SUBCHAPTER 1 18 33-1. 1 General provisions Taxable periods Finality determination of fraud Procedure with respect to closing agreements Applicability and coverage policy Procedures a The Director of the Division of Taxation or any of his delegated representatives may enter into a written agreement with any person relating to the liability of such person or of the person or estate for whom he acts in respect to any State tax administered by the Director of the Division of Taxation for any entered into in any case in which there appears to be an advantage in having the case permanently and conclusively closed or if good and sufficient reasons are shown by the taxpayer for desiring a closing agreement and it is determined by the director that the State of New Jersey will sustain no disadvantage through consummation of such an agreement. A Closing Agreement Form 906 to complete. Appointment of Taxpayer Representative if applicable. A Financial Statement of Debtor Section I through Section V to be completed* National Standard Expenses information to be used in the completion of Section II of Financial Statement of Debtor. NOTE Copies of the Taxpayer s last two years Individual IRS returns and Corporate returns if applicable are required to be submitted with Form 906. Send completed required information to New Jersey Division of Taxation 9th Floor PO Box 245 Trenton NJ 08695-0245 Authority Unless otherwise expressly noted all provisions of this chapter were adopted pursuant to authority of N*J*S*A.
Form preview Delegation of service agreemen... PHYSICIAN ASSISTANT DELEGATION OF SERVICES AGREEMENT A Delegation of Services Agreement is to be maintained at each practice site and is to be available to DOPL upon request. In order to prescribe controlled substances the physician assistant must have obtained his or her own controlled substance license and DEA registration. The physician assistant may not use his or her supervising physicians controlled substance licenses or DEA registrations. PROCEDURES ADDRESSING SITUATIONS OUTSIDE THE PHYSICIAN ASSISTANT S SCOPE OF PRACTICE PROCEDURES FOR PROVIDING BACKUP FOR THE PHYSICIAN ASSISTANT IN EMERGENCY SITUATIONS ADDITIONAL CONSIDERATIONS RELATING TO OUR PRACTICE Signature of Physician Assistant Date of Signature Signature of Supervising Physician NOTE It is unprofessional conduct under the Physician Assistant Practice Act to fail to reflects current practices or to fail to make the Delegation of Services Agreement. PRESCRIBING OF CONTROLLED SUBSTANCES schedules of controlled substances and a current DEA registration covering the appropriate is within the prescriptive practice of the supervising physician and also within the delegated prescribing stated in the delegation of services agreement and the supervising physician co-signs any medical chart record of a prescription of a Schedule 2 or Schedule 3 controlled substance made by the physician assistant. In order to prescribe controlled substances the physician assistant must have obtained his or her own controlled substance license and DEA registration. The physician assistant may not use his or her supervising physicians controlled substance licenses or DEA registrations. Physician assistants may authenticate with their signature any form that may be authenticated by a physician signature. PRESCRIBING OF CONTROLLED SUBSTANCES schedules of controlled substances and a current DEA registration covering the appropriate is within the prescriptive practice of the supervising physician and also within the delegated prescribing stated in the delegation of services agreement and the supervising physician co-signs any medical chart record of a prescription of a Schedule 2 or Schedule 3 controlled substance made by the physician assistant. It consists of written criteria jointly developed by a physician assistant s supervising physician and any substitute supervising physicians and the the supervising physicians to assist in the management of illnesses and injuries common to the physician s scope of practice. The following information must be legible. Use additional sheets if necessary. DO NOT SUBMIT YOUR DELEGATION OF SERVICES AGREEMENTS TO DOPL WITH YOUR APPLICATION FOR LICENSURE. Supervising Physician Name Utah License Number Substitute Supervising Physician s Name PRACTICE SITE S Name of Facility Address City State Zip DEGREE AND MEANS OF SUPERVISION the health care needs of the practice population and ensure that the patient s health safety and welfare will not be adversely compromised. There shall be a method of immediate consultation by electronic means whenever the physician assistant is not under the direct supervision of the 100 direct supervision. There shall be a method of immediate consultation by electronic means whenever the physician assistant is not under the direct supervision of the supervising physician. FREQUENCY AND MECHANISM OF CHART REVIEW The degree of onsite supervision shall be outlined in the Delegation of Services Agreement maintained at the site of practice. Physician assistants may authenticate with their signature any form that may be authenticated by a physician signature.

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