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Sample Collaborative Practice Agreement - Updated

1* template * Collaborative Practice Agreement for Advanced Practice Registered Nurses Requesting Prescriptive Authority Rule 848 IAC 5-1-1 Initial Authority to Prescribe Legend Drugs 1. Complete names, home and business addresses, zip codes, and telephone numbers of the licensed practitioner and the advanced Practice registered nurse:Licensed Practitioner: Licensed Practitioner name and license number Street address of home City, State & Zip of home Home phone number Business street address City, State & Zip of business Business phone number Advanced Practice Registered Nurse: Advanced Practice Registered Nurse name and license number, Street address of home City, State & Zip of home Home phone number Business street address City, State & Zip of business Business phone number 2.

*TEMPLATE* Collaborative Practice Agreement for Advanced Practice Registered Nurses Requesting Prescriptive Authority Rule 848 IAC 5-1-1 – Initial Authority to Prescribe Legend Drugs 1. Complete names, home and business addresses, zip codes, and telephone numbers of the licensed practitioner and the advanced practice registered nurse:

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