Get Ky Rescission Of A Collaborative Agreement For The Prescriptive Authority For Controlled Substances 2021-2025

This guide provides a comprehensive overview of how to accurately fill out the KY Rescission Of A Collaborative Agreement For The Prescriptive Authority For Controlled Substances online. Follow the steps outlined below to ensure that all necessary information is provided correctly.

Follow the steps to fill out the KY rescission form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the appropriate editor for completion.
2. Complete the date fields, specifying the day, month, and year when the collaborative agreement is being rescinded. This information is essential for clarity.
3. In the provided sections, enter the last name of the physician clearly. Ensure that the name is legible to avoid any issues with processing.
4. Next, fill in the APRN last name and first name, maintaining clarity in your writing as it will be used for identification purposes.
5. Enter the Kentucky APRN License number and the physician's first name clearly in the designated fields.
6. Provide the physician's license number and complete the practice name, practice address, and practice city, state, and zip code accurately.
7. Ensure that at least one party listed on the form signs it. Include both the APRN and the physician's signatures in the appropriate sections.
8. Finally, record the date each party signed the form and review all entries to confirm accuracy before submission.
9. Upon completion, save changes, and securely upload the form to the APRN portal for processing.

Take the next step towards completing your documentation online today.