Prescriptive Authority Agreement Explanation Page
***This page is not be included in your final agreement
For APRNs who are not considered facility based delegation must be thru a Prescriptive Authority Agreement (PAA) and it is
recommended that “Prescriptive Authority Agreement” be used in the title. Facility based APRNs may choose to use a PAA for
delegation but if they do so then all requirements of a PAA must be met. This includes the face to face monthly quality meetings
with delegating physician. For must facility based APRNs it is more appropriate to use a “protocol”. Please see the Baylor Scott
& White Health North Texas Division Delegation of Medical Acts and Prescriptive Authority Protocol for Nurse Practitioners and
Clinical Nurse Specialists.
PAAs do not need to describe exact steps that APRNs must take and should be written so APRNs may use their education and
judgment in order to provide care for patients
This document is a template and should be used as starting point in developing a PAA that reflects the APRN(s)’ practice. All
parties to the PAA should participate in the development. The delegating physician(s) must determine what medical acts he/she
will delegate. The document should be reviewed, signed and dated at least annually. It may be done more frequently if needed.
This template is specifically for nurse practitioners and clinical nurse specialists. CRNAs and midwives have other
laws/regulations related to their practice which were not reviewed while constructing this document therefore not included.
The material in the document that is italicized and highlighted in yellow is to provide clarification and direction. This material
should not be included in the final agreement that will be signed by all participating parties. Please read the document carefully
and use the material that is applicable to your practice. For instance there are some sections that have many options to choose
from depending on what the delegating physician(s) chooses to delegate.
Quality improvement requirements for non-facility based APRNs are mandated by law. A face-to-face meeting must occur
monthly until the 3rd anniversary of the date the agreement is executed and then quarterly. Meetings held between quarterly
meetings may be thru electronic communication that includes video conferencing or the internet. The electronic method must
permit each participant to view images of other participants. If primary delegating physician or physician group changes then the
in-person meeting requirement is reset.
The PAA must include:
-name, address and all professional license number of parties to agreement (include DPS and DEA #s)
-nature of practice, practice locations/settings (name and address of each location in which PAA will be executed)
-types of categories of drugs or devices APRN may or may not prescribe (include any blood products)
-general plan for consultation and referral
-plan to address patient emergencies
-general process for communicating information between APRN and physician
-may designate physicians assuming QAI and supervisory duties on temporary basis (optional)
-describe a prescriptive authority QAI plan, specifying methods to document plan implementation. At a minimum the
QAI plan must include a chart review (number of charts to be determined by physician and APRN) and nature &
frequency of the meetings required in statue (face to face meetings)
-reviewed and signed annually
-may include other provisions that are not mandated
Other Documents that should be reviewed by all APRNs
- Quick facts for APRN Practice in Texas
- Physician APRN Facts
Other Documents that may or may not apply to your practice:
Consultation Agreement Template
- Call Prescriptions on Behalf of APRN Template
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Baylor Scott & White Health North Texas Division Prescriptive Authority
Agreement for Nurse Practitioners and Clinical Nurse Specialists
This prescriptive authority agreement (PAA) is for the practice of Advanced Practice Registered Nurses
(APRNs). The PAA is applicable to the practice of Nurse Practitioners and Clinical Nurse Specialists who are
associated with or employees of The Baylor Scott & White Health North Texas Division or applicable partners.
Purpose [optional section]
This PAA authorizes the APRN(s) to perform medical acts, including prescribing and ordering drugs and
medical devices and receiving and distributing drug samples, in accordance with the Nursing Practice Act,
§301.152, Texas Occupations Code and the Medical Practice Act, §157.051 – 157.060, Texas Occupations
Code. This PAA delegates certain medical acts, as authorized or required by Texas law, and sets forth guidelines
for collaboration between the delegating physician(s) and the APRN(s). This agreement is not intended to limit
the healthcare services the APRN(s) shall provide under his or her scope of practice, based on the advanced
practice role and specialty authorized by the Texas Board of Nursing (BON).
Development, Revision, Review and Approval [optional section]
The PAA is developed collaboratively by the APRN(s) and delegating physician(s). The PAA must be reviewed
annually, dated, and signed by all the parties named in the PAA. Alternate physician(s), if designated, are not
required to sign the document. The PAA may be revised more frequently as necessary. With the exception of
amending the list of alternate physicians, if designated, amendments must be signed and dated by all parties.
Any changes to documents referenced in the PAA, must also be approved by all parties to the agreement.
Signing the “Statement of Approval” signifies the parties approve the agreement and all policies, protocols
and/or procedures referenced in this document. The parties are entering into a collegial relationship in which
each party understands and will fulfill his/her legal responsibilities under the terms of the agreement. APRNs
and any delegating physicians who join the staff after approval or renewal of this agreement will also review and
sign the agreement. APRNs must sign the agreement before prescribing or ordering any drugs or medical
devices.
Each APRN and physician must retain a signed copy of the agreement until the second anniversary after the
delegating relationship is terminated.
Requirements and Disclosures [optional section]
The APRN must be licensed in good standing as a Registered Nurse and as an APRN with prescription
authorization from the Texas Board of Nursing in a role and population focus area appropriate to the population
of patients for whom the APRN will prescribe or order drugs and medical devices. APRNs shall not be a party
to a PAA if under a Board Order prohibiting their participation. If prescriptive authority for controlled
substances is delegated, the APRN must also have a Texas Department of Public Safety Controlled Substances
Permit and a Drug Enforcement Agency (DEA) certificate. The APRN must also possess a valid Basic Life
Support (BLS) and Advance Life Support Certificate (ACLS) in accordance with facility or practice policies in
which they practice.
Each delegating physician must hold a full and unencumbered Medical License issued by the Texas Medical
Board. The physician is limited to delegating to no more than the full-time equivalent (1 FTE = 50 hours) of
seven APRNs and physician assistants.
Before executing this agreement, the physician and APRN must disclose to all other prospective parties any
prior disciplinary action taken by the respective licensing board. Within 30 days of executing this agreement,
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the physician and APRN must complete the Texas Medical Board’s “Prescriptive Delegation Registration.”
Any party to this agreement will notify the other parties immediately if, at any time while this PAA is in effect,
a licensing board notifies the person he/she is under investigation.
Nature of the Practice and Locations
The APRNs will treat [insert the type of practice and population of patients to be cared for by APRN, ex: adult
and gerontological patients admitted to the xx service, patients of all ages in a facility based hospital emergency
room] at the following practice site(s):
Include facility name, complete address
Name, Address and Professional License Numbers of Parties to the PAA [Add as many rows to table as
necessary, may include this information on signature page rather than place here. APRNs must list TX DPS and
DEA numbers if physician is delegating prescriptive authority for controlled substances.]
_____________________________________________________
Delegating Physician’s Name and Professional Title
_____________________________________________________
Address
_____________________________________________________
Delegating Physician’s Name and Professional Title
_____________________________________________________
Address
_____________________________________________________
APRN’s Name and Professional Titles
_____________________________________________________
Address
_____________________________________________________
APRN’s Name and Professional Titles
_____________________________________________________
Address
_____________
TMB License #
_____________
TX DPS #
_________________________
City
_____________
TMB License #
_________
State
_____________
TX DPS #
_________________________
City
_________
State
_____________
RN License #
_____________
APRN License #
_____________
TX DPS #
_____________
DEA #
_________________________
City
_________
State
_____________
RN License #
_____________
APRN License #
_____________
TX DPS #
_____________
DEA #
_________________________
City
_________
State
_____________
DEA #
_________________
Zip Code
_____________
DEA #
_________________
Zip Code
_____________
Rx Auth #
_________________
Zip Code
_____________
Rx Auth #
_________________
Zip Code
Delegation of Prescriptive Authority and Medical Acts [This section should be modified in accordance with
medical acts being delegated]
The APRN may establish medical diagnoses for patients who are within the APRN’s scope(s) of practice, and
order or prescribe drugs. The APRN may order/prescribe medical devices, including medical supplies, durable
medical equipment, prosthetics or orthotics as authorized by the Texas Board of Nursing and the Texas Medical
Board rules and regulations. The APRN may also receive and distribute samples for drugs they are permitted to
prescribe. These services/functions are not an exhaustive description of the APRN practice but rather
illustrative of the types of medical aspects of care the APRN will perform. The APRN may perform medical
functions and procedures as privileged by the facility in which the APRN provides care. These functions
include, but are not limited to, performing physical examinations and medical histories, ordering and
interpreting laboratory tests and radiologic exams, providing health promotion and safety instructions,
evaluation and management of acute episodic illnesses and stable chronic diseases, and referrals to other health
care providers, as needed.
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A. Prescriptive Authority
The APRN(s) may order or prescribe: [The law states that physicians may delegate ordering and prescribing
nonprescription drugs but there is no requirement to further specify categories of these drugs. The PAA,
however, must specify the drugs or categories of Dangerous drugs that may or may not be ordered or
prescribed. If no limitations, specify that all categories of dangerous drugs are included, or if there are
limitation, specify those limitations. Other options might include drugs that may or may not be generically
substituted and the number of refills the APRN may prescribe. No limitations are required by law. The legal
definition of “dangerous drugs” includes medical devices. Therefore, if there are any limitations of prescribing
medical devices, also note that in this section and modify other suggested language, as necessary.]
1. Nonprescription and Dangerous Drugs (The term includes a device or a drug that bears or is required to
bear the legend: "Caution: federal law prohibits dispensing without prescription" or "RX only" or
another legend that complies with federal law)
A
[choose one statement]
The APRN(s) may order and prescribe all categories of nonprescription drugs and dangerous
drugs that are within the APRN’s scope of practice without limitations on dosage units or refills
other than those listed elsewhere in this protocol.
The APRN(s) may order and prescribe all categories nonprescription drugs and of dangerous
drugs that are within the APRN’s scope of practice without limitation on dosage units or refills,
except those listed elsewhere in this protocol and for the following:
B When prescribing dangerous drugs, generic substitution for all drugs is permitted.
C The APRN may prescribe investigational drugs as part of a research protocol as directed by his or
her supervising physician
D BON Rule 222.4 (e) limits the drugs APRNs may prescribe to those that are FDA approved unless
part of a research protocol or the APRN can show evidence-based research that prescribing the
drug is within the standard of care for the disease or condition being treated.
2. Controlled Substances, Schedules III - V [these limitations are required by law. May specify any other
limitations the delegating physician places]
A Limited to a 90-day supply or less
B No new prescriptions or refills after the initial 90-day supply without prior consultation with the
physician.
C No prescription for children under 2 years of age without prior consultation with the physician.
D Prior consultation must be noted in the patient’s record.
E In accordance with §481.071, Health & Safety Code, an APRN may not prescribe an anabolic
steroid or human growth hormone listed in Schedule III.
3. Controlled Substances, Schedule II
[Non-facility Based]
The APRN(s) may not sign a prescription for a Schedule II Controlled Substance to be filled by an
outpatient pharmacy under this PAA agreement. Pursuant to the standing medical order below, the
APRN(s) may select and write dispensing and administration directives for the following Schedule II
Controlled Substances for administration to hospital in-patients or for patients being treated in the
emergency room or out-patient setting within the parameters specified below.
1. The APRN(s) with prescriptive authority from the Texas BON may only execute this
standing medical order in [specify each practice facility by name].
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2. The signs and symptoms requiring treatment with Schedule II Controlled Substances are:
severe pain related to acute and chronic illnesses or shivering as applicable [may include
additional criteria as applicable]
3. The Schedule II Controlled Substances that may be prescribed include:
Drug
Morphine Sulfate
Hydromorphone (Dilaudid)
Fentanyl
Codeine
Oxycodone
Methadone
Demerol
Dose Parameters
Frequency parameters
[Facility Based or Hospice NPs/CNS. Applies only to APRN seeing hospice patients, patients being treated in a
hospital ER or admitted as inpatient with estimated length of stay greater than 24 hours. The setting in which
the APRN may prescribe these drugs should be specified]
APRNs may order and prescribe the following categories of Schedule II Controlled Substances for
[choose applicable statement: hospice patients, patients in the hospital emergency room, and/or
hospitalized inpatients with an intended length of stay greater than 24 hours]:
Opiates to manage pain [list other symptoms, as appropriate]
Stimulants to manage fatigue
Depressants to manage sleep disturbances
4. The APRN may prescribe all blood products as applicable for patient care.
B. Drug Samples [optional section, however includes information that is difficult to obtain and the BON
requires APRNs to maintain this documentation]
The APRN(s) may accept, sign for and distribute prescription drug samples. The APRN(s) must retain any
receipt they sign when receiving drug samples. In addition, the APRN must note in the patient’s chart any
sample distributed and comply with BHCS facility policy on the documentation and/or distribution of drug
samples. The date, drug, dosage, frequency and duration of treatment must be noted in the patient’s chart and
included on the sample distributed to the patient. The APRN may also wish to maintain a record of distribution
that includes the date of distribution, the patient’s name, the name and strength of the drug, the lot number,
and/or directions for use.
C. Persons Who May Call Prescription to the Pharmacy as Directed by the APRN [optional section]
The physician designates any licensed vocational nurse or registered nurse working or volunteering in this site
as a person who may orally transmit a prescription into a pharmacy on behalf of the APRN(s). A list of the
person authorized to orally communicate prescriptions to the pharmacy must be maintained at the practice site
and will be made available to a pharmacist upon request. [Any such person(s) should be designated by name
and can be listed here or elsewhere]
D. Medical Procedures [optional section][this section is to identify medical procedures the APRN may perform
that would not be within the APRN’s normal scope of practice. It should not include procedures that all RNs
can perform and those commonly performed by this type of APRN. List procedures that require training beyond
that usually taught in most educational programs for the APRN’s role and population focus. However if want to
include it is acceptable to list procedures that are standard for APRNs practicing on a particular service or may
refer to job description or privileging documents].
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The APRN may perform medical procedures in accordance with their education and training as specified on
facility privileging documents.
E. Medical Verifications for Disabled Parking Placards [optional section, no need to include if this does not
apply to the APRN’s practice. However delegation is required so if it is not included then the APRN is unable to
sign verification for initial application of disabled parking placard]
The APRN may sign a prescription or notarized statement for patients that meet the legal requirements for a
temporary disabled parking placard. The APRN is limited to signing verifications that will accompany the
initial application for patients. Subsequent renewals for temporary parking placards must be signed by the
physician.
Qualifying conditions:
1. Persons with a mobility problem that substantially impairs the ability to ambulate including:
a. cannot walk 200 feet without stopping to rest
b. cannot walk without the use of or assistance from an assistance device, including a brace,
cane, a crutch, another person, or a prosthetic device
c. cannot ambulate without a wheelchair or similar device
d. is restricted by lung disease to the extent that the person’s forced respiratory expiratory
volume for one second, measured by spirometry, is less than one liter, or the aterial oxygen
tension is less than 60 millimeters of mercury on room air at rest
e. uses portable oxygen
f. has a cardiac condition to the extent that the person’s functional limitations are classified in
severity as class III or class IV according to standards set by the American Heart Association
g. is severely limited in the ability to walk because of an arthritic, neurological or orthopedic
condition
2) Persons with visual disabilities including:
a. visual acuity of 20/200 or less in the better eye with correcting lenses
b. a limited field of vision in which the widest diameter of the visual field subtends an angle of
20 degrees or less.
F. Authorizing and Ordering Certain Services Reimbursed by the Texas Medicare Program, CHIP or Early
Childhood Intervention (ECI) Programs. [Optional section, only include if applicable to your practice. The
APRN would normally be able to order these services for patients of any age as part of their independent scope
of practice. However, a Texas Medicare Rule states APRNs may order the services if the physician delegates
that authority].
The APRN may determine medical necessity and sign any documentation related to providing the following
services to persons insured by Texas Medicaid, CHIP or ECI who are age 20 years or younger:
1.
2.
3.
4.
Private Duty Nursing
Physical therapy
Occupation therapy
Speech therapy
General Plan for Consultation and Referral: [Law requires that the PAA include a “general plan for
addressing consultation and referral.” There may be legal implications, so nothing specific should be included
that does not always trigger consultation or referral. Goal of this is to clarify the relationship between the
APRN and physician and avoid miscommunications. The APRN and physician should discuss and identify any
situations in which consultation is expected.
The delegating physician(s) (or designated physician(s)) are available for consultation at any time. However,
the APRN may seek consultation and refer patients directly to the most appropriate health care provider to treat
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the patient’s condition when, in the APRN’s judgment, such steps are necessary for optimal resolution of the
patient’s problem. Whenever a physician is consulted or patient referred, a notation to that effect, should be
recorded in the patient’s medical record. Consultations and referrals may also be discussed at quality assurance
and improvement meetings.
Plan for Patient Emergencies [this is an example of what might be included in the PAA. The plan should be
specific to the type of patients in the practice and more detail may be added. The bracketed statements below
are examples of reporting requirement that could be included. Additional detail might include any level of CPR
certification the APRN is required to maintain and/or emergency drugs and medical devices required to be
maintained on site].
If the APRN determines that the immediate health and wellbeing of the patient is at risk, the APRN must take
immediate steps to stabilize the patient while having a staff member initiate emergency protocols. This may
include but is not limited to calling 911 for response by emergency medical services and transport to an
emergency room or calling appropriate hospital code for response of emergency medical services. [As soon as
possible, the APRN is to report any emergency situation of this nature to the delegating physician].
For emergencies that require immediate treatment, but the life of the patient is not in immediate danger, the
APRN must take steps to assure the patient’s safety and comfort. If the patient’s condition is beyond the usual
type of conditions treated by the APRN, h/she immediately consults the authorizing or alternate physician, or a
physician specialist, as most appropriate. [If the authorizing physician was not notified, the APRN reports the
emergency to the authorizing physician as soon as possible].
In case of an emergency in which serious permanent harm or aggravation of injury or disease is imminent, or in
which the life of patient is in immediate danger, the APRN may provide care to stabilize a patient’s condition
and/or prevent deterioration of a patient’s condition, to the degree authorized by the APRN’s licensure,
registration or certification. This includes providing care to patients outside the type of practice and population
listed in this agreement until another a physician or other appropriate profession is available.
General Communication Process Concerning Patient Care and Treatment
The delegating physician will be available by telephone or email [add any other type of communication
commonly used in this practice such as telemedicine or videoconferencing.] If discussions reveal the patient’s
identity, HIPPA complaint forms of communication will be used. Daily communication between the APRN and
the delegating physician is not required, but the physician will be available to discuss patient care and treatment
upon the request of the APRN. At a minimum, at the quality assurance and improvement meetings specified
below, the APRN and authorizing physician or if designated, an alternate physician will discuss patient care and
treatment plans for patients with complex problems, or problems the APRN does not have experience treating.
The physician or APRN will have additional meetings, when either party thinks patient care would benefit from
more frequent communication and requests additional time to discuss patient care and treatment.
Quality Assurance and Improvement (QAI) Plan and Documentation Additional QA measures may be
added to the plan, but anything included in the plan must be implemented and documented. For instance, if
physicians in the practice have regular peer review meetings, APRNs can be included in those meetings. If
alternate physician are designated in the practice, then provisions must be made for alternate physicians to
perform the chart review]
[Non-Facility Based]
Chart Review: [state the method by which charts will be reviewed, ex, by electronic health records/at each faceto-face meeting] the delegating physician or in the absence of the authorizing physician, an alternate will review
at least [insert number] randomly selected charts. The APRN may present any additional charts the APRN
wishes to review based on questions about diagnosis and treatment plan. The APRN will document the number
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of charts reviewed by [state method, ex, making a list, grouped by date, of his/her patients’ charts the physician
reviewed]. If the physician and APRN are practicing in separate locations, the authorizing physician will retain a
copy of any documentation verifying the chart review. Copies of this documentation will be retained while this
PAA is in effect and for two years after the date the PAA is terminated. [If the EHR system records the charts
the physician reviews, then that would be an alternative, but it is still recommended that both parties maintain
meeting and chart review records.]
QAI Meetings: QAI meetings are held monthly to share information related to patient treatment and care,
changes needed in patient care plans, issues related to referrals, and patient care improvement. The APRN will
record the date and time of each meeting, whether the meeting was face-to-face or by other means. All records
of face-to-face meetings will include the patients/topics discussed. If the physician and APRN are practicing in
separate locations, the authorizing physician will retain a copy in addition to the copy the APRN retains. Copies
of the documentation will be retained while this PAA is in effect and for two years after the date the PAA is
terminated. The day, time or location of any QAI meeting may be changed at the prior request of either party
with the other’s consent as long as the statutory requirements for meetings are met.
The delegating physician, or if unavailable, the alternate physician will meet in person monthly until three years
from the date the PAA was originally signed (a total of 36 meetings). Thereafter, the physician and APRN will
meet face-to-face quarterly, with monthly meeting in between held via HIPPA compliant videoconferencing.
The usual date and time for meetings will be [insert the date and time agreed upon by the APRN and physician,
ex, the 1st Wed of each month at 4:30 P.M.]. In person, face-to-face meetings will be held at [insert location
agreed upon by parties. Specify how remote electronic communications will occur].
[Facility Based]
Evaluation of the APRN(s) will be provided in the following ways [below are examples only, change as related
to your practice, in congruence with facility policy and procedure, and preference of delegating physician]:




Informal evaluation during consultations and case review
Weekly rounds
Monthly department meetings, QI meetings
Chart reviews
Medical Records [optional section]
The APRN(s) is/are responsible for the complete, legible documentation of all patient encounters in a manner
consistent with BHCS facility policy as well as state and federal laws.
Alternate Physicians [optional section]
If the delegating physician is unavailable for any reason, alternate physician(s) may assume the consultation,
supervisory and quality assurance and improvement responsibilities of the authorizing physician. The
authorizing physician may amend this list by written notice to all parties. The following may serve as alternate
physicians: [list the physicians and their contact information]
References
Woolbert, L. (2013). Prescriptive authority agreement sample. Austin, TX: Coalition for Nurses in
Advanced Practice.
Texas Administrative Code, Title 22, Part 9. Texas Medical Board, Board Rule. Chapter 193. Standing
Delegation Orders §193.1-193.20
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Texas Administrative Code, Title 22, Part 11. Texas Board of Nursing Advanced Practice Nurses.
Chapter 221. Definitions. §221.1. §221.2, §221.8, §221.11, §221.12, §221.13
Texas Administrative Code, Title 22, Part 11. Texas Board of Nursing Advanced Practice Nurse.
Chapter 222. Prescriptive Authority. §222.1-§222.10
Woolbert, L. F., & Ziegler, B. (2013). A guide for APRN practice in Texas (4th ed.). Austin, TX:
Coalition for Nurses in Advanced Practice and Texas Nurse Practitioners.
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Prescriptive Authority Agreement Signature Page for [insert current year]
I, one of the undersigned, affirm I reviewed and agree to the term of this Prescriptive Authority Agreement. I
agree to fulfill the responsibilities set forth in the document. I declare that I meet the requirements to be a party
to this agreement and have disclosed any prior disciplinary actions taken by my licensing board. I will inform
other parties to the agreement if I am notified my licensing board is investigating my practice while this PAA is
in effect.
_______________________________________________________
Authorizing Physician’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
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APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
_______________________________________________________
Authorizing Physician’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
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Approval Date
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APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
_______________________________________________________
APRN’s Signature
__________________
Approval Date
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Form #1: Record of Alternate Physician Supervision for Delegated Prescriptive
Authority
APRN’s Name ____________________________ License #_________ Rx# ________
Delegating Physician’s Name__________________________ License #__________
Dates of Supervision by an Alternate Physician
Begin
End
Signature of Alternate Physician
License #
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By signing this log sheet, I affirm that I served as the alternate physician for the purposes of supervising
prescriptive authority of this APRN for the dates specified. I acknowledge my responsibility to consult
with and perform quality assurance and improvement activities with this advanced practice registered
nurse pursuant to the Prescriptive Authority Agreement.
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Form #2: Record of Chart review or Other QAI Activity
Date
Patient Name or Chart Number
Chart
Reviewed
Consult
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Date of QAI Meeting: ____/____/____
Physician Signature
APRN Signature
Patient
Referred
□
Case
Presented
□
TX Plan
Revised
□
Beginning Time: _________ End Time: ________
Printed Name:
Printed Name:
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Form #3: Distribution Record for Drug Samples
Date
Distributed
Patient’s Name
Drug
Lot #
Strength
Directions for Use
Distributing
Practitioner
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Form #4: Record of Delegation of Prescriptive Authority and PAA Review
APRN’s Name
Name & Address of Practice
Locations/s
(if different than physician’s)
Type of APRN
Delegating Physician: ____________________________
Practice Designation/s
Dates of Delegation
Initiated:
RN License #
APRN License #
Terminated:
APRN Rx #
DEA #
DPS #
Dates of PAA
Approval/Review
APRN’s Name
Name & Address of Practice
Locations/s
(if different than physician’s)
Type of APRN
Practice Designation/s
Dates of Delegation
Initiated:
RN License #
APRN License #
Terminated:
APRN Rx #
DEA #
DPS #
Dates of PAA
Approval/Review
14
15