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APPENDIX A
CHANGE OF CROP PROGRAM DIRECTOR
This user guide describes the process to request a change of Program Director. This process may only be
submitted by the Program Provider.
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How to fill out crnp-prescriptive-authority-collaborative-agreement
01
Obtain a copy of the crnp-prescriptive-authority collaborative agreement form.
02
Read the instructions and requirements on the form carefully.
03
Fill out your personal information such as name, contact details, and license number.
04
Provide details of your collaborating physician, including their name, contact information, and license number.
05
Specify the scope of practice and prescriptive authority being granted by the collaborating physician.
06
Include any additional information or clauses required by your state's regulations.
07
Sign and date the agreement.
08
Submit the completed agreement to the appropriate governing body for review and approval.
Who needs crnp-prescriptive-authority-collaborative-agreement?
01
Nurse Practitioners (CRNPs) who wish to have prescriptive authority.
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What is crnp-prescriptive-authority-collaborative-agreement?
The CRNP Prescriptive Authority Collaborative Agreement is a legal document that allows Certified Registered Nurse Practitioners (CRNPs) to prescribe medications in collaboration with a licensed physician.
Who is required to file crnp-prescriptive-authority-collaborative-agreement?
CRNPs who wish to obtain prescriptive authority to prescribe medications must file the CRNP Prescriptive Authority Collaborative Agreement.
How to fill out crnp-prescriptive-authority-collaborative-agreement?
To fill out the CRNP Prescriptive Authority Collaborative Agreement, the CRNP must provide their personal information, the collaborating physician’s details, and specify the nature of the collaboration and prescriptive authority being granted.
What is the purpose of crnp-prescriptive-authority-collaborative-agreement?
The purpose of this agreement is to establish a formal collaboration between a CRNP and a physician to ensure safe and effective patient care through shared decision-making in prescribing medications.
What information must be reported on crnp-prescriptive-authority-collaborative-agreement?
The agreement must report the names and licenses of both the CRNP and the collaborating physician, the types of medications the CRNP is authorized to prescribe, and the specific terms of their collaborative practice.
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