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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