Please add language to allow a Nurse Practitioner, in addition to a physician, to order Skilled Nursing services under Waiver for a person in services.  Many people in services rely on rural health clinics or residencies that employ a limited number of physicians and are primarily staffed by nurse practitioners.  Most residents with complex medical needs in my agency have nurse practitioners assigned as their primary medical care providers, and the NPs are most familiar and attentive to their situations, diagnoses, and health care requirements.  Having to wait for physician signatures on skilled nursing service orders (as requested by PA consultants at times) has created delays in obtaining these documents, as MDs in rural clinics often work part time or contractually.  This may create problems obtaining community-based nursing care for vulnerable individuals who need it.