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Get Prescriptive Authority & Protocol Agreement

Registered Nurse (APRN) or Physician Assistant (PA) Information Name: License Number: Type of Practitioner: (select one) Advanced Practice Registered Nurse Physician Assistant *DEA Permit #: Practice Site DEA Exp. Date: Name of Practice Site Address Type of Practice Site #1 Site #2 Site #3 *Provide a Drug Enforcement Administration (DEA) Permit if delegating the prescribing or ordering of CIII-CV controlled substances Purpose This document authorizes the APRN or PA to perform medi.

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