ADDRESS: Phone#: CERTIFICATION INFORMATION: (PLEASE CHECK THE APPROPRIATE BOX) CERTIFIED NURSE MIDWIFE PSYCHIATRIC/MENTAL HEALTH SPECIALIST NURSE PRACTITIONER Procedures being performed by the APRN are within competency of their certification specialty. OR Procedures being performed by the APRN that are not within competency of their certification spec.
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How to fill out the GA Form C online
Filling out the GA Form C is a crucial process for advanced practice registered nurses (APRNs) and their delegating physicians. This guide provides step-by-step instructions to help you complete the form accurately online.
Follow the steps to fill out the form effectively.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling in the delegating physician’s name and license number. Ensure this information is accurate and legible.
- Next, input the APRN’s name and RN number. Similar to the previous step, this information must be filled out clearly.
- Provide the address and phone number for the APRN. This information is essential for contact purposes.
- In the certification information section, check the appropriate box to indicate the APRN's specialty: Certified Nurse Midwife, Psychiatric/Mental Health Specialist, or Nurse Practitioner.
- If procedures outside the normal scope are being performed, list them below the provided fields and include documentation of training and competency as per the instructions.
- After completing the required fields, ensure to have both the APRN and delegating physician sign and date the form. Remember that electronic signatures are not accepted.
- Once the form is complete, save changes, and use options to download or print the form for submission.
Complete your GA Form C online today to ensure proper compliance and documentation.
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