Prescriptive Authority Agreement
Attachment A Effective: 10/30/2013 Reviewed: 10/19 1 Prescriptive Authority Agreement Physician Information Name: License Number: Address of Primary Practice Site: Address of Other Practice Site: Address of Other Practice Site: Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) Information Name: License Number: Type of Practitioner: (select one) Advanced practice registered nurse Physician assistant *DEA Permit #: DEA Exp. Date: *DPS Permit #: DPS Exp. Date: Name of Practice Site Address Type of Practice Site #1 Site #2 Site #3 * Provide a Drug Enforcement Administration (DEA) Permit or Department of Public Safety (DPS) Permit Number if delegating the prescribing or ordering of CIII-CV controlled su
The agreement is developed collaboratively by the delegating physician and APRN or PA. It will be reviewed at least annually, dated, and signed by the physician and APRN or PA.
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