FORM D ADVANCED PRACTICE REGISTERED NURSE (APRN ...

FORM D ADVANCED PRACTICE REGISTERED NURSE (APRN)

DEA INFORMATION

INSTRUCTIONS:

Type or print clearly. Complete all information requested.

DELEGATING PHYSICIAN INFORMATION

PHYSICIAN NAME: (PLEASE PRINT LEGIBLY) ___________________________________________________________ GEORGIA LICENSE NUMBER: __________________________

DEA REGISTRATION NUMBER: __________________________

APRN DEA INFORMATION

APRN NAME: (PLEASE PRINT LEGIBLY) ___________________________________________________________

APRN LICENSE NUMBER: __________________________

DEA REGISTRATION NUMBER: __________________________

DATE ISSUED: __________________________

Please return the completed form to: Georgia Composite Medical Board

Attn: APRN Department 2 Peachtree Street, N.W., - 36th Floor

Atlanta, GA 30303 Or by fax: 770-408-5879

________________________________________ Delegating Physician Telephone Number

________________________________________ Delegating Physician Signature

FORM D ? APRN DEA INFORMATION

__________________________________ e-mail address

__________________________________ Date

REVISED: 1/2010

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