Fillable (309) APN Controlled Substance User Guide (State of Illinois Department of Financial & Professional Regulation)

Fill Online, Printable, Fillable, Blank (309) APN Controlled Substance User Guide (State of Illinois Department of Financial & Professional Regulation) Form

Use Fill to complete blank online STATE OF ILLINOIS DEPARTMENT OF FINANCIAL & PROFESSIONAL REGULATION pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

(309) APN Controlled Substance User Guide (State of Illinois Department of Financial & Professional Regulation)

On average this form takes 6 minutes to complete

The (309) APN Controlled Substance User Guide (State of Illinois Department of Financial & Professional Regulation) form is 8 pages long and contains:

  • 1 signature
  • 4 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your State of Illinois Department of Financial & Professional Regulation forms online.

BROWSE STATE OF ILLINOIS DEPARTMENT OF FINANCIAL & PROFESSIONAL REGULATION FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
(309) Advance Practice Nurse
Controlled Substance License
Contents
General Information .........................................................................................................................................................................2
Advance Practice Nurse Mid-Level Practitioner ...........................................................................................................................2
Overview of Requirements .......................................................................................................................................................2
In Order to Obtain a Mid-Level Practitioner Controlled Substance License.............................................................................3
Authority to Prescribe or Dispense Legend Drugs ....................................................................................................................3
Instructions: ..................................................................................................................................................................................4
Additional Information: ................................................................................................................................................................5
Application Requirements ................................................................................................................................................................6
Application Fees ...............................................................................................................................................................................7
2
General Information
Advance Practice Nurse Mid-Level Practitioner
Pursuant to Section 1300.430 of the Rules for the Administration of the Illinois Nurse Practice Act: A
collaborating physician who delegates limited prescriptive authority to an advanced practice nurse shall
include such delegation in the written collaborative agreement. The prescriptive authority may include
prescription and dispensing of legend drugs and controlled substances categorized as Schedule II, III, IV, or V
controlled substances, as defined in the Illinois Controlled Substances Act. An APN who has been given
controlled substances prescriptive authority shall be required to obtain a mid-level practitioner controlled
substances license in accordance with 77 Ill. Admin. Code Part 3100. The physician shall file a notice of
delegation of prescriptive authority with the Department. The delegation of authority form shall be submitted
to the Department prior to the issuance of a controlled substances license. The APN may only prescribe and
dispense within the scope of practice of the collaborating physician. All prescriptions written and signed by an
advanced practice nurse shall indicate the name of the collaborating physician. The collaborating physician's
signature is not required. The advanced practice nurse shall sign his/her own name. An APN may receive and
dispense samples per the collaborative agreement. Medication orders shall be reviewed periodically by the
collaborating physician.
Overview of Requirements
If the collaborating physician has delegated prescriptive authority to the advanced practice nurse, the
written collaborative agreement shall include a statement indicating the supervising physician has
delegated prescriptive authority for legend drugs and/or Schedule II, III, IV, or V controlled substances.
The collaborating physician may delegate authority for any or all of these schedules. The delegation
must be within the physician’s scope of practice and within the scope of the advanced practice nurse’s
training. The written collaborative agreement shall be signed by both the physician and the advanced
practice nurse and a copy maintained at each location where the advanced practice nurse practices.
In addition to the requirements above, if the advanced practice nurse is delegated prescriptive
authority of Schedule II controlled substances the following guidelines apply. Specific Schedule II
controlled substances by oral dosage or topical or transdermal application may be delegated. This
delegation must identify specific Schedule II controlled substance by either brand or generic name and
must be attached to the collaborative agreement. Schedule II controlled substances to be delivered by
injection or other route of administration may not be delegated. Evidence of completion of at least 45
graduate contact hours in pharmacology must be submitted to obtain Schedule II prescriptive
authority. The collaborating physician may only delegate controlled substances that he or she
prescribes. Any prescription must be limited to no more than a 30-day supply, with any continuation
authorized only after prior approval of the collaborating physician.
If the collaborating physician wishes to terminate the delegated prescriptive authority for Schedule II,
III, IV, or V Controlled Substances, you are instructed to provide the collaborating physician with the
Notice of Termination of Delegated Prescriptive Authority for Controlled Substances form for his/her
completion. The form should be returned to the Department's Springfield address.
3
In Order to Obtain a Mid-Level Practitioner Controlled Substance License
The collaborating physician shall submit a notice of prescriptive authority indicating the advanced
practice nurse has been delegated prescriptive authority. If the advanced practice nurse is
collaborating with more than one physician, a separate notice of prescriptive authority shall be
submitted by each collaborating physician. If prescriptive authority includes Schedule II, III, IV, or V
controlled substances, the advanced practice nurse will be required to apply for a mid-level
practitioner controlled substances license in accordance with the Illinois Controlled Substances Act.
The collaborating physician is required to complete the Notice of Delegated Prescriptive Authority for
Controlled Substances, which must be on file with the Department, prior to the issuance of a mid-level
practitioner’s controlled substances license.
Authority to Prescribe or Dispense Legend Drugs
There is no form required to be fi led with the Department to prescribe or dispense legend drugs. Any
delegation for prescriptive authority for legend drugs should be included in the written collaborative
agreement.
4
Instructions:
1. A mid-level practitioner controlled substances license will not be issued until your advanced practice
nurse license has been issued.
2. If applying for schedule II prescriptive authority, submit an official transcript with school seal affixed
to document and completion of 45 graduate hours in pharmacology.
3. It is mandatory that the permanent mailing address and/or business address be a street address. P.O.
boxes are not acceptable. Your controlled substances registration must be issued to a street address.
4. You must select the drug schedules for which you are applying for. Drug schedules include:
Schedule II
Schedule III
Schedule IV
Schedule V
5. You have three (3) years from the date your application is received by the Department to complete the
application process. If the process is not completed in three (3) years, your application will be denied
and the fee forfeited.
6. Application fees for controlled substance licenses are $5.00 and are non-refundable.
7. Your Illinois advanced practice nurse mid-level practitioner controlled substances license number will
expire at the same time your professional license expires.
8. A State controlled substances registration is a prerequisite for Federal controlled substances
registration. The address on your Illinois controlled substances registration must be exactly the same
address as your Federal registration. For information concerning Federal registration, you must
contact:
Drug Enforcement Administration
230 South Dearborn, Suite 1200
Chicago, Illinois 60604
Telephone: 312/353-7875
Web site: www.deadiversion.usdoj.gov
5
Additional Information:
If the collaborating physician has delegated prescriptive authority to the advanced practice nurse, the
written collaborative agreement shall include a statement indicating that the collaborating physician
has delegated prescriptive authority for legend drugs and/or Schedule II, III, IV, and V controlled
substances. The delegation must be within the physician's scope of practice and within the scope of
the advanced practice nurse's training.
The written collaborating agreement shall be signed by both the physician and the advanced practice
nurse and a copy maintained at each location where the advanced practice nurse practices and shall be
provided to the Illinois Department of Financial and Professional Regulation upon request. A copy of
the advanced practice nurse Illinois and federal controlled substances licenses numbers shall be kept
with the agreement.
If the advanced practice nurse is delegated prescriptive authority of Schedule II controlled substances
the following guidelines apply. Specific Schedule II controlled substances by oral dosage or topical or
transdermal application may be delegated. This delegation must identify specific Schedule II controlled
substance by either brand or generic name and must be attached to the collaborative agreement.
Schedule II controlled substances to be delivered by injection or other route of administration may not
be delegated. Evidence of completion of at least 45 graduate contact hours in pharmacology must be
submitted to obtain Schedule II prescriptive authority. The collaborating physician may only delegate
controlled substances that he or she prescribes. Any prescription must be limited to no more than a
30-day supply, with any continuation authorized only after prior approval of the collaborating
physician.
If collaborating with more than one physician, a separate notice of delegation of prescriptive authority
shall be submitted when prescriptive authority is delegated. If prescriptive authority includes Schedule
II, III, IV and/or V controlled substances, the advanced practice nurse will be required to apply for a
mid-level practitioner controlled substances license in accordance with the Illinois Controlled
Substances Act; however, only one controlled substances license will be issued regardless of the
number of collaborating physicians.
6
Application Requirements
Designation
Requirements
Submitted:
Controlled Substance
License Application
1. Completed online application including all of the following
required information:
Public and Mailing Address
Social Security Number or an SSN Affidavit
Name Change Information
Date of Birth
2. Personal Information including:
Birth City
Birth State
Birth Country
Gender
Ethnicity
3. Select your delegating Physician from the grid and add the drug
schedules they will be delegating to you:
Schedule II
Schedule III
Schedule IV
Schedule V
4. Would you like your controlled substance license to be issued to
the business address of your delegating physician or would you
like it to be issued to a different location?
5. If it is not issued to the location of your delegated physician enter
the public address where it should be issued to.
6. Personal History questions related to the Health Care Workers
Charged with or Convicted of Criminal Acts including:
Are you currently charged with or have you been convicted of
a criminal act that requires registration under the Sex
Offender Registration Act as a part of a criminal sentence?
Are you currently charged with or have you been convicted of
a criminal battery against any patient in the course of patient
care or treatment, including any offense based on sexual
conduct or sexual penetration?
Are you currently charged with or have you been convicted of
a forcible felony?
ONLINE
PORTAL
7
7. If you answered yes to any of the above statements, please attach
a certified copy of the court records regarding your conviction,
description of the nature of the offense, date of discharge, if
applicable, and a statement from the probation or parole office.
8. Personal History Information including:
Criminal History
Felony Convictions
Dishonorable discharge from military service
Disease or conditions that may interfere with professional
work
Denial of a prior professional license
9. Failure to comply with a child support order, defaulting on a
student loan, or defaulting on taxes.
Application Fees
Fees collected through the licensing process are NOT REFUNDABLE OR TRANSFERABLE.
License Type
Submitted:
(309) Advance Practice Nurse Controlled Substance License ………………….……….……………….….……. $5.00
ONLINE
PORTAL
NOTES: All major credit and debit cards as well as ACH and eCheck are accepted.
Notice of Delegated Prescriptive
Authority for Controlled Substances
(Advanced Practice Nurse)
APN-CS
COLLABORATING PHYSICIAN:
Complete this form as offi cial notifi cation you are delegating prescriptive authority for controlled substances for
the advanced practice nurse named herein. Submit form to:
Department of Financial and Professional Regulation
ATTN: Division of Professional Regulation
320 West Washington, 3rd Floor
Springfi eld, Illinois 62786
Upon your decision to terminate the delegated prescriptive authority for controlled substances for this individual,
you must notify the Department of your intent by completing a Notice of Termination of Delegated Prescriptive
Authority.
This notice, as well as other forms required for Advanced Practice Nurse Licensure and for the Mid-level
Practitioner Controlled Substance License, can be downloaded from the IDFPR Web site at: www.idfpr.com.
3. SOCIAL SECURITY NUMBER
Profession Name
Profession Code
4. ADDRESS STREET, CITY, STATE, ZIP CODE
5.
7. MAIDEN OR GIVEN SURNAME
6. LICENSE NUMBER OF ADVANCED PRACTICE NURSE
(If unknown, leave blank.)
2. DATE OF BIRTH
1. NAME OF ADVANCED PRACTICE NURSE (Last, First, Middle Initial)
__ __ __ - __ __ - __ __ __ __
Month Day Year
__ __ / __ __ / __ __ __ __
Advanced Practice Nurse Mid-level Practitioner
Controlled Substances License 3 0 9
This is to certify that I, ___________________________________________, have delegated
prescriptive authority to_________________________________________ in order to prescribe and/or
dispense controlled substances categorized as Schedule II, III, IV, or V controlled substances, as defi ned in
Article II of the Illinois Controlled Substances Act. I further certify the delegation of prescriptive authority is ap-
propriate to my practice and within the scope of the advanced practice nurse’s training. The advanced practice
nurse named hereinabove may prescribe and/or dispense (please check appropriate box(es)):
Schedule(s) II
* III IV V 
IL486-1881 03/12 (APN)
(Advanced Practice Nurse)
(Collaborating Physician)
IMPORTANT NOTICE: Completion of this form
is required by 225 ILCS 95/1, et.seq. of the Illinois
Compiled Statutes. Disclosure of this information
is mandatory. Any person who is found to have
knowingly violated any provision of this Act is guilty
of a Class A misdemeanor.
Additional forms can be downloaded from the IDFPR Web site at www.idfpr.com.
8. APN CONTROLLED SUBSTANCE NUMBER
Illinois License Number of Collaborating Physician
Print Name of Collaborating Physician
Date of Delegation of Prescriptive Authority
Signature of Collaborating Physician
Illinois Controlled Substance Number
Business Street Address of Collaborating Physician
City, State, Zip Code
*Such delegation shall be in accordance with the provisions set forth in Section 303.05 a)2)B of the Illinois Controlled Sub-
stances Act.
click to sign
signature
click to edit
Notice of Termination of Delegated Prescriptive
Authority for Controlled Substances
(Advanced Practice Nurse)
3. SOCIAL SECURITY NUMBER
4. ADDRESS STREET, CITY, STATE, ZIP CODE
2. DATE OF BIRTH
1. ADVANCED PRACTICE NURSE NAME (Last. First, Middle)
__ __ __ - __ __ - __ __ __ __
Month Day Year
__ __ / __ __ / __ __ __ __
This is to certify that I, ___________________________________________, hereby terminate the
prescriptive authority delegated to_________________________________________ Illinois Licensed
Advanced Practice Nurse, License No. _________________, effective ______________________ . This
person is no longer delegated authority to prescribe and/or dispense controlled substances by this collabo-
rating physician:
_______________________________________ ______________________________________
_______________________________________
_______________________________________
Illinois License Number of Collaborating Physician
Print Name of Collaborating Physician
Date of Termination of Prescriptive Authority
Signature of Collaborating Physician
IL486-1883 10/04 (APN)
(Advanced Practice Nurse)
(Collaborating Physician)
COLLABORATING PHYSICIAN: Complete this form as offi cial notifi cation you are terminating the delegated
prescriptive authority for controlled substances for the advanced practice
nurse named herein and submit it to:
Department of Financial and Professional Regulation
ATTN: Division of Professional Regulation
320 West Washington, 3rd Floor
Springfi eld, Illinois 62786
This notice, as well as other forms required for Advanced Practice Nurse
Licensure and for the Mid-level Practitioner Controlled Substance License,
can be downloaded from the IDFPR Web site at: www.idfpr.com
5. LICENSE NUMBER OF ADVANCED PRACTICE
NURSE
IMPORTANT NOTICE: Completion of this form
is required by 225 ILCS 95/1, et.seq. of the Illinois
Compiled Statutes. Disclosure of this information
is mandatory. Any person who is found to have
knowingly violated any provision of this Act is guilty
of a Class A misdemeanor.
Additional forms can be downloaded from the IDFPR Web site at www.idfpr.com.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

(309) APN Controlled Substance User Guide (State of Illinois Department of Financial & Professional Regulation)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document