Get TN DoH PH #3625 2011-2024

11398 or 615 532-3202 ext. 11398 TENNESSEE BOARD OF NURSING ADVANCED PRACTICE NURSE AUTHORIZATION FOR PRESCRIBING ADVANCED PRACTICE NURSE Advanced Practice Nurse Name TN/Multi-state Registered Nurse Number Name of Practice/Clinic Address City State Zip Code Work Phone Number PLEASE DELETE Delete Name/Clinic Delete Supervising Physician s PLEASE ADD Add Supervising Physician s PH 3625 REV. STATE OF TENNESSEE DEPARTMENT OF HEALTH HEALTH RELATED BOARDS 227 FRENCH LANDING SUITE 300 HERITAGE PLACE METRO CENTER NASHVILLE TENNESSEE 37243 NOTICE AND FORMULARY 800 778-4123 ext. 12/11 Page 1 RDA SW05 This section must be completed by the supervising physician s. This page may be duplicated if necessary List all practice settings Setting Supervising Physician Signature Printed Name DEA Number I MD/DO License Number Signature do hereby delegate the above prescribing authority to am the supervising physician and will assume the responsibility according to TCA 63-7-123. APN of whom I APN do hereby accept the delegated function of prescribing authorization and will utilize it as such according to TCA 63-7-123. Signature of Advanced Practice Nurse Page 2 Date Check the classification of drugs authorized to prescribe Analgesics Anesthetics Enzymes Antihistamines Electrolytic Caloric Water Balance Expectorants and Cough Preparations Antihypertensive Eye Ear Nose and Throat Preparations Anti-infective Agents Gastrointestinal Drugs Anti-inflammatory Agents Hormones and Synthetic Substitutes Anti-neoplastic Agents Hyperglycemic Agents Antispasmodics and Anticholinergics Migraine Preparations Antivirals Muscle Relaxant Preparations Arthritis Medications Narcotic Antagonists Autonomic Drugs Oxytocics Blood Derivatives Psychotropics Blood Formation and Coagulation Serum Toxoids and Vaccine Birth Control Drugs and Devices Skin and Mucous Membrane Preparations Bronchodilators/Anti-asthma Drugs Smoking Cessation Aids Cardiovascular Drugs Smooth Muscle Relaxants Central Nervous system Drugs Spasmolytic Agents Contraceptives Sympathomimetics and Combination Diabetic Agents Vitamins Diagnostic Agents Schedule II Decongestants PLEASE RETURN ORIGINAL BY MAIL TO DO NOT FAX NASHVILLE TN 37243 PLEASE NOTE DO NOT COMPLETE A NEW PROFILE FOR CHANGES IN SUPERVISING PHYSICIAN s. 12/11 Page 1 RDA SW05 This section must be completed by the supervising physician s. This page may be duplicated if necessary List all practice settings Setting Supervising Physician Signature Printed Name DEA Number I MD/DO License Number Signature do hereby delegate the above prescribing authority to am the supervising physician and will assume the responsibility according to TCA 63-7-123. APN of whom I APN do hereby accept the delegated function of prescribing authorization and will utilize it as such according to TCA 63-7-123. APN of whom I APN do hereby accept the delegated function of prescribing authorization and will utilize it as such according to TCA 63-7-123. Signature of Advanced Practice Nurse Page 2 Date Check the classification of drugs authorized to prescribe Analgesics Anesthetics Enzymes Antihistamines Electrolytic Caloric Water Balance Expectorants and Cough Preparations Antihypertensive Eye Ear Nose and Throat Preparations Anti-infective Agents Gastrointestinal Drugs Anti-inflammatory Agents Hormones and Synthetic Substitutes Anti-neoplastic Agents Hyperglycemic Agents Antispasmodics and Anticholinergics Migraine Preparations Antivirals Muscle Relaxant Preparations Arthritis Medications Narcotic Antagonists Autonomic Drugs Oxytocics Blood Derivatives Psychotropics Blood Formation and Coagulation Serum Toxoids and Vaccine Birth Control Drugs and Devices Skin and Mucous Membrane Preparations Bronchodilators/Anti-asthma Drugs Smoking Cessation Aids Cardiovascular Drugs Smooth Muscle Relaxants Central Nervous system Drugs Spasmolytic Agents Contraceptives Sympathomimetics and Combination Diabetic Agents Vitamins Diagnostic Agents Schedule II Decongestants PLEASE RETURN ORIGINAL BY MAIL TO DO NOT FAX NASHVILLE TN 37243 PLEASE NOTE DO NOT COMPLETE A NEW PROFILE FOR CHANGES IN SUPERVISING PHYSICIAN s. .