LARA/BPL-OPTOMEMERGPLAN (Rev. 10/18)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
MANAGEMENT AND EMERGENCY PLAN
Authority: 1978 PA 368
Applicant’s Name (First, Middle, Last)
10-Digit MI Permanent ID/License Number
Address
City
State
Zip Code
Date of Plan Completion
Date
REFERRALS: List the names and addresses of at least three physicians (MD or DO), physician clinics, or hospitals in Michigan to whom
you will refer patients with adverse drug reactions. Be sure at least one is skilled or specializes in the diagnosis or treatment of the eye
(board eligible or certified ophthalmologist). An optometrist may Include the patient's primary care physician for a physician named in the
plan, but shall not substitute the patient's primary care physician for a physician named in the plan who specializes in the diagnosis and
treatment of diseases of the eye.
City
State
Zip Code
Name of Second Referral
PLAN: The following management plan will be in operation in my office:
1. I
will refer patients with an adverse drug reaction to appropriate medical specialists or facilities.
2. I will routinely advise each patient, and so note in their record, to contact me if the patient experiences an adverse drug reaction.
3. I will place information in each patient’s permanent record describing any adverse drug reaction experienced by the patient, and the date and
time any referral was made.
4. A C
OPY OF THIS MANAGEMENT AND EMERGENCY PLAN WILL BE KEPT IN MY OFFICE.
__________________
_______________________________ ____________________________________________
Signature of Applicant Date
