Prescriptive Authority Agreement Physician Information ...

Attachment A Effective: 10/27/ 2020 (D) Replaces: 10/27/2020 (A) Reviewed: 10/2021 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 Number if delegating the prescribing or ordering of CIII-CV controlled substances Purpose This document authorizes the APRN or PA to perform medical acts in accordance with the Nurse Practice Act, , Texas Occupations Code and the Medical Practice Act, 157, Texas Occupations Code.

Nursing or Texas Physician Assistant Board and the Texas Medical Board (TMB). The physician and APRN or PA will maintain a record of the agreement. A log of the dates in which an alternate physician assumes delegation duties in the absence of the delegating physician will also be maintained with this protocol at the APRN’s or PA’s practice ...

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