Division of Professions and Occupations State Board of Nursing—Advanced Practice Nursing 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-2430 www.colorado.gov/dora/Nursing
Advanced Practice Nurse APPLICATION FOR FULL PRESCRIPTIVE AUTHORITY (RXN)
NO FEE
APPLICANT INSTRUCTIONS This application is ONLY to be used by applicants who currently hold active provisional prescriptive authority in Colorado. If you do not currently hold prescriptive authority in Colorado, you must apply online by Original or Endorsement: www.colorado.gov/dora/Nursing_APN_Applications_Docs. If you have 1,000 hours in another state and have developed an articulated plan, you may submit this application at the same time as you submit your application for provisional prescriptive authority. Basic Requirements. All applicants must hold an active, unencumbered Colorado Registered Nurse license OR an active, unencumbered Compact Multi-state Registered Nurse license. Information about the Nurse Licensure Compact, including a current listing of Compact states, is available on the Board’s website at: www.colorado.gov/dora/Nursing. Requirements for inclusion on the Advanced Practice Registry are outlined in the Nurse Practice Act, Section 12-38-111.5 of the Colorado Revised Statutes (C.R.S.), and the Board’s Chapter 14 rules, both available at: www.colorado.gov/dora/Nursing. In compliance with the Michael Skolnik Medical Transparency Act of 2010, all applicants are required to complete and maintain an online Healthcare Professions Profile on our website at: www.colorado.gov/dora/HPPP. About the Application. This application is to be completed by you and returned to the State Board of Nursing. All questions on the application are mandatory, and all supporting documentation and the appropriate fee must be received before the application is considered complete. You may copy as many forms as needed; however, each form submitted must be an original, completed in ink or typed. Keep a copy of the completed application for your records. Application Expiration. Your application will be kept on file for one (1) year from date of receipt at the State Board of Nursing. Your file and all supporting documentation will be purged if you do not submit required documents and complete the application process in one year. At that time, you will be required to submit a new, current application, all supporting documentation, and the current application fee. Disclosure of Addresses. Consistent with Colorado law, all addresses and phone numbers on record with the Division are public record and must be provided to the public when requested. It is your responsibility to keep your contact information current in our system. If your address is not current, you may not receive important information from the Division Your email address is not open to public record, but must be provided in this application. Any requests for additional information, license information and renewal notices will be emailed to the email address on record. If your email address is not current, it is possible you will not receive important information from the Division. You can change your contact information online by using Online Services at: www.dora.colorado.gov/professions/onlineservices. Each Application Requires Its Own Documentation. You must provide all documentation requested in these instructions even if you have submitted the same or similar documentation with previous applications. Each application must stand on its own merit. All supporting documentation must be provided by you, the applicant, and be attached to this application, unless otherwise noted. Note: An Advanced Practice Registered Nurse must apply for and be granted Prescriptive Authority before beginning to prescribe independently in Colorado. For inquiries regarding DEA numbers to prescribe controlled substances, contact the Drug Enforcement Administration at www.deadiversion.usdoj.gov. Printing your License upon Approval. DORA is no longer printing and mailing wallet cards as licenses. To print your wallet card license in its current status, login to your Online Services account at: www.dora.colorado.gov/professions/onlineservices and select “Print Your License” in the left-hand menu.
Applicant: Keep this page for your records.
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Division of Professions and Occupations State Board of Nursing—Advanced Practice Nursing 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-2430
Advanced Practice Nurse APPLICATION FOR FULL PRESCRIPTIVE AUTHORITY (RXN)
www.colorado.gov/dora/Nursing
NO FEE
APPLICANT CHECKLIST To apply for Full Prescriptive Authority (RXN) as an Advanced Practice Registered Nurse (APRN): You must hold a Colorado Registered Nurse (RN) or multi-state RN license in your primary state of residence. You must have an unencumbered Active Advanced Practice Nurse (APN) in Colorado. You must have an unencumbered Active-Provisional Prescriptive Authority in Colorado and ONE of the following: You have at least 1,000 hours of prescribing experience and Active prescriptive authority in another state; OR You have completed 1,000 hours mentorship in Colorado AFTER being granted provincial prescriptive authority. You must attach ALL out of state Prescriptive Authority verification(s). Online verification(s) are preferred. Verification must include original issue date and expiration date. You must have developed an Articulated Plan verified by a Colorado physician or Nurse with FullPrescriptive Authority. Complete the attached application. Return the completed application and all supporting documentation to the State Board of Nursing. If you wish to be granted full prescriptive authority in more than one role and/or population(s), you must submit evidence requested in this application for each role and/or population focus. .
Your scope of practice as an Advanced Practice Registered Nurse with Prescriptive Authority is determined by your education and certification in the role and population focus for which you are recognized on the Advanced Practice Registry. See the Board’s Chapter 14 and Chapter 15 rules at: www.colorado.gov/dora/Nursing. Provide documentation of any name change. If your name has changed since you obtained a previously-issued license, or if your name is different on any of your supporting documentation, you must provide a copy of the legal document verifying the name change (i.e., marriage license, divorce decree, or court order). Update your online Healthcare Professions Profile. Once your application is approved, you must update your Healthcare Professions Profile on our website at: www.colorado.gov/dora/HPPP. Your Healthcare Professions Profile is an ongoing responsibility; a profile must be updated online within 30 days of changes and/or reportable events. Prescribing controlled substances requires a DEA number. Contact the Drug Enforcement Administration at: www.deadiversion.usdoj.gov.
NO FAXES OR COPIES PLEASE. Return your completed application packet and all supporting documentation to: Division of Professions and Occupations State Board of Nursing—Advanced Practice Nursing 1560 Broadway, Suite 1350 Denver, CO 80202
Applicant: Keep this page for your records.
02/2017
Division of Professions and Occupations State Board of Nursing—Advanced Practice Nursing 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-2430
Application Advanced Practice Nurse FULL PRESCRIPTIVE AUTHORITY (RXN)
NO FEE
www.colorado.gov/dora/Nursing The content of this application must not be changed. If the content is changed, the applicant may be referred to the Colorado State Attorney General’s office for violation of Colorado law.
PART 1—LICENSE INFORMATION RN License Number:
Issuing State:
Expiration Date:
Colorado Advanced Practice Registry Number:
Expiration Date:
Colorado Provisional Prescriptive Authority Number:
Expiration Date:
APRN Certification Number (in the Role & Population Focus):
Expiration Date:
Select the Population(s) for which you are applying for full prescriptive authority (NP & CNS ONLY): Population(s) for NP and CNS: Acute Care
Family
Neonatal
Adult
Geriatric
Pediatric
Psychiatric/Mental Health
Other: _________________
Women’s Health
Select the APN role you currently hold and for which you are applying for full prescriptive authority: Nurse Practitioner (NP) Clinical Nurse Specialist (CNS) Certified Nurse Midwife (CNM) Certified Registered Nurse Anesthetist (CRNA) PART 2—APPLICANT INFORMATION Middle:
Name: First:
Last:
Suffix:
Previous Name(s): Social Security Number: * E-mail Address: (This will be the primary communication method) PO Box, Street:
Mailing Address: This is a
Home
Business
Daytime Telephone Number: (
City, State, Zip:
)
Date of Birth (mm/dd/yyyy):
Place of Birth (city and state, or foreign country):
Prescriptive Authority Application (RXN)
Gender:
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Male
Female
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APPLICANT NAME: ______________________________________________
PART 3 — ATTESTATION — COMPLETION OF COLORADO MENTORSHIP APPLICANT: The Nurse Practice Act and the Colorado State Board of Nursing Chapter 15 Rules require that Advanced Practice Registered Nurses requesting Full Prescriptive Authority (RXN) complete 1,000-hour mutually structured mentorship with a physician or an advanced practice nurse with full-prescriptive authority practicing in Colorado and whose practice corresponds with the role and population focus of the advanced practice nurse(see chapter 15, section 1.12 and 1.13). The mutually structured mentorship was completed within the time frame specified in section 12-38-111.6(4.5)(b)(I)(D), C.R.S.
I state under penalty of perjury, as defined in section 18-8-503, C.R.S., that by signing this Attestation, I have completed ___________ hours of a mutually structured mentorship in accordance with the requirements of section12-38-111.6(4.5)(b)(I)(A C.R.S., and State Board of Nursing Chapter 15 Rules. ____________________________________________________________________________________________________________ Licensee Signature
Date
PHYSICIAN MENTOR ATTESTION: I state under penalty of perjury, as defined in section18-8-503, C.R.S., that by signing this Attestation I participated in the mutually structured mentorship for the above-named Advanced Practice Registered Nurse in compliance with the requirements of 12-36-106 (4)(1), C.R.S., and State Medical Board Rule 950. Name of Physician: ___________________________________________________________________________________________ Physician License Number: ____________________________________________________________________________________ Practice Area: ________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Physician Signature
License Number
Date
OR RXN MENTOR ATTESTATION: I state under penalty of perjury, as defined in section18-5-503, C.R.S., that by signing this Attestation I participated in the mutually structured mentorship for the above-named Advanced Practice Registered Nurse in compliance with the requirements of section12-38111.6(4.5)(b)(I)(A), C.R.S., and State Board of Nursing Chapter 15 Rules. Name of RXN: _________________________________________________________________________________________________ RXN License Number: _________________________________________________________________________________________ Practice Area: ________________________________________________________________________________________________ __________________________________________________________________________________________________________ RXN Signature
License Number
Date
More than one part 3 may be submitted for each mentor
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APPLICANT NAME: ______________________________________________
PART 4 — ATTESTATION — PRESCRIBING EXPERIENCE IN ANOTHER STATE The prescribing experience may be attested to by a physician or an Advanced Practice Registered Nurse with FullPrescriptive Authority in a state other than Colorado. The above-named Advanced Practice Registered Nurse has completed _____________ hours of independent prescribing experience. I attest that the applicant’s prescribing practices were with the specific drugs relevant to the scope of practice, Role and Population Focus of the applicant and within the generally accepted standards of prescriptive practice for an Advanced Practice Registered Nurse with Prescriptive Authority. Physician or RXN Printed Name: _______________________________________________________________________ Physician or RXN License State: _______________________________________________________________________ Physician or RXN License Number: _____________________________________________________________________ ___________________________________________________________________________________________________ Physician Signature License Number Date
OR ___________________________________________________________________________________________________ Advanced Practice Nurse with Prescriptive Authority Signature License Number Date I have attached a copy of ALL out of state Prescriptive Authority verification(s). Online version preferred. Verification must include original issue date and expiration date.
PART 5 —ATTESTATION – DEVELOPMENT OF ARTICULATED PLAN APPLICANT: The Nurse Practice Act and the Colorado State Board of Nursing Chapter XV Rules require that Advanced Practice Nurses requesting Full Prescriptive Authority (RXN) develop an Articulated Plan for safe prescribing in compliance with chapter 15, section 6.The Articulated Plan shall be retained by the RXN, shall be reviewed annually and appropriately updated, and shall be available to the State Board of Nursing upon request. I state under penalty of perjury, as defined in section18-8-503, C.R.S., that by signing this Attestation, I have developed an articulated plan in compliance with the requirements of section12-38-111.6(4.5)(b)(II), C.R.S., and the State Board of Nursing Chapter 15 Rules. ____________________________________________________________________________________________________________ Licensee Signature Date
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APPLICANT NAME: ______________________________________________
PART 5 —ATTESTATION – DEVELOPMENT OF ARTICULATED PLAN (Continued) PHYSICIAN ATTESTION: I state under penalty of perjury, as defined in 18-8-503, C.R.S., that by signing this Attestation I assisted in the development of the initial articulated plan for the above-named Advanced Practice Nurse in compliance with the requirements of section12-26-106.4(2), C,R.S., and State Medical Board Rule 950. Name of Physician: ___________________________________________________________________________________________ Physician License Number:_____________________________________________________________________________________ Practice Area: ________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Physician Signature License Number Date
OR RXN ATTESTATION: I state under penalty of perjury, as defined in section18-8-503, C.R.S., that by signing this Attestation I assisted in the development of the initial articulated plan for the above-named Advanced Practice Registered Nurse in compliance with the requirements of section12-38111.6, C.R.S., and State Board of Nursing Chapter 15 Rules. Name of RXN:_________________________________________________________________________________________________ RXN License Number: _________________________________________________________________________________________ Practice Area: ________________________________________________________________________________________________ __________________________________________________________________________________________________________ RXN Signature License Number Date
PART 6—DECLARATION OF PRIMARY STATE OF RESIDENCE “Primary State of residence” is defined as the State of a person’s declared fixed permanent and principal home for legal purposes; domicile. You may be required to provide proof of residency. I declare that the state of primary state of residence and that such constitutes my permanent and principal home for legal purposes.
is my
Note: If you declare Colorado as your primary State of residence, you must obtain, reactivate, or reinstate a Colorado RN license prior to applying for the Advanced Practice Registry). Primary Residence Street: Physical Address: (PO Boxes are not accepted)
City, State, Zip:
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APPLICANT NAME: ______________________________________________
PART 7—PROFESSIONAL LIABILITY INSURANCE _____ Initials
By initialing this box, I attest that I carry and/or will carry, and maintain upon commencement of independent practice, professional liability insurance in an amount of not less than $500,000 (five hundred thousand dollars) per claim with an aggregate liability limit for all claims during the year of $1,500,000 (one million five hundred thousand dollars) or that I claim one of the exemptions authorized in the Board's rules regarding liability insurance.
ATTESTATION Under the Nurse Practice Act, providing false information to the Board is grounds for denial, suspension, or revocation of a Registered Nurse license. I state under penalty of perjury in the second degree, as defined in section18-8-503, C.R.S., that the information contained in this application is true and correct to the best of my knowledge. In accordance with section18-8-501(2)(a)(I), C.R.S., false statements made herein are punishable by law and may constitute violation of the practice act.
Applicant Signature
Prescriptive Authority Application (RXN)
Date
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