Get Advanced Practice Np Pa New Or Renewal Application ... - Mass.gov - Mass

Completing the Advanced Practice Nurse Practitioner and Physician Assistant New or Renewal Application is a crucial step in obtaining your Massachusetts Controlled Substances Registration. This guide provides a comprehensive overview of each section of the application to assist you in accurately filling it out, ensuring that all necessary information is provided for a smooth processing experience.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to obtain the application document and open it in your preferred platform for editing.
2. Select the application type by checking either 'New' or 'Renewal' in the designated box.
3. In the classification section, select one of the options that best describes your role, such as RN/NP, RN/NM, RN/PC, RN/NA, or PA.
4. Enter your Massachusetts Board of Registration License number accurately.
5. If applicable, enter your DEA Controlled Substance Registration number.
6. Fill in your personal details, including your first name, middle name, last name, and any suffix if relevant.
7. Provide your business address. Ensure that you include a street address, as applications with only a P.O. Box may not be processed.
8. Input your mailing address, checking the box if it is the same as your business address.
9. Enter your business telephone number, including the area code.
10. Provide your Social Security number, which is a requirement.
11. Select the drug schedules you are requesting by checking all that apply: II, III, IV, V, or VI.
12. Optionally, enter your email address for correspondence.
13. Respond to the questions regarding any past convictions related to controlled substances and any prior license issues. Attach a letter if you answer 'Yes' to these questions.
14. Complete the supervising physician’s section, providing their information including name, contact number, address, and license numbers.
15. Ensure that the supervising physician signs and dates the application, affirming the existence of written guidelines.
16. Sign and date the application yourself, confirming all information provided is accurate and that you understand the legal obligations.
17. Review the application thoroughly, then save your changes, download, print, or share the completed form as needed.

Complete your Advanced Practice NP PA New or Renewal Application online today for efficient processing.