Get Controlled Substance Verification Form - Kansas Board Of Nursing

This guide provides comprehensive instructions for users on how to accurately fill out the Controlled Substance Verification Form required by the Kansas Board of Nursing. Following these steps will ensure that you complete the form correctly and submit it without issues.

Follow the steps to complete the Controlled Substance Verification Form online

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Select the appropriate option for your application type: Initial Application or Change.
3. Enter your APRN name as it is registered.
4. Input your Kansas APRN License Number.
5. Enter your Kansas RN License Number.
6. Check your APRN role from the options provided: Clinical Nurse Specialist, Nurse Midwife, or Nurse Practitioner.
7. Provide the expiration date of your licenses.
8. Fill in your business address, ensuring it includes the street address.
9. Identify the name of the responsible physician under whose protocol you operate.
10. Enter the physician’s Kansas License Number.
11. Have the responsible physician sign and date the form.
12. Indicate your authorization to prescribe controlled substances by checking ‘NONE’, ‘ALL’, or specifying exceptions for each schedule: Schedule II, Schedule IIN, Schedule III, Schedule IIIN, Schedule IV, and Schedule V.
13. Answer the questions pertaining to DEA registration, marking ‘YES’ or ‘NO’ as applicable.
14. If applicable, provide explanations for any negative answers to DEA registration questions.
15. Sign and date the application where indicated.
16. Ensure anyone named as your responsible physician also signs and dates next to their name.
17. Do NOT attach a copy of your collaborative agreement or DEA number with this form.
18. Return the completed Controlled Substance Verification Form to the Kansas State Board of Nursing, or fax it to the provided number.

To ensure compliance, complete your documents online as required.