Controlled Substance Verification Form (Please Print or Type) Current Business Address:

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1 WPPA, Inc. ProviDRs Care Network 1102 S. Hillside Wichita, KS Controlled Substance Verification Form (Please Print or Type) APRN Name: Kansas Certification Number: Expiration : Check your APRN Category Clinical Nurse Specialist Nurse Midwife Nurse Practitioner Attention: The Nurse anesthetist does not have statutory authority to obtain a DEA number. Attention: APRN s may choose not to participate in prescribing controlled substances. Those individuals not wishing to participate do not need to complete and submit this form. Current Business Address: A change in principal place of business needs to be reported within 10 days. Name of Responsible Physician On The Protocol Physician's Kansas License Number A Controlled Substance Verification Form must be submitted to the Board for the APRN to prescribe controlled substances. Further, in no case shall the scope of the authority of the APRN to prescribe controlled substances, exceed the normal and customary practice of the responsible physician in the prescribing of drugs. To prescribe controlled substances, the APRN must register with the Drug Enforcement Administration to obtain a DEA number. The APRN is authorized to prescribe controlled substances as follows based on protocols with responsible physician: NONE ALL ALL Except Specify Schedule II Schedule IIN Schedule III Schedule IIIN Schedule IV Schedule V INFORMATION PERTAINING TO DEA REGISTRATION YES NO 1. Responsible physician has a current DEA number? 2. APRN has a current DEA number? 3. Has the DEA placed restrictions on the responsible physician and/or APRN for prescribing controlled substances in any schedules? If the answer is "no" to question 1 or 2, please provide explanation: First Time DEA Applicant Other: If the answer is "yes" to question 3, please provide explanation: APRN Signature Supervising Physician s Signature

2 MID-LEVEL PRACTITIONER CLINICAL PRACTICE GUIDELINES APPLICANT PA/APRN is to mark each procedure being requested. Column 1 may be done by PA/APRN when physician is present. Column 2 may be done by PA/APRN when physician is not present. REQUESTED PROCEDURES COLUMN 1 COLUMN 2 Perform & dictate a complete history Perform & dictate a physical examination Write Progress Notes Dictate discharge summaries Obtain post mortem consents Draw blood specimens Catheterization Perform arterial punctures Venous punctures Determine visual fields Pass nasogastric tubes Perform Pap smears Perform gastric lavage & gavage Perform skin biopsies Perform I & D of superficial abscess Perform venous cutdowns Removal of minor skin lesions Removal of ingrown toenails Assist in surgery Assist in recovery Order inhalation therapy Order IV Fluids Order Medications Order Diet Therapy Order Patient Activities

3 REQUESTED PROCEDURES COLUMN 1 COLUMN 2 Order X-ray examinations Order Laboratory procedures Order EKG s Order EEG s Order audiometry tests Order ambulance Order physical therapy Order consultations Apply casts Order Isolation Removal of casts Removal of superficial foreign bodies Spinal Tap Thoracentesis Paracentesis Sigmoidoscopy Perform emergency life saving procedures in the presence of life threatening situations such as cardiac or respiratory arrest, massive hemorrhage, etc. Perform intubations Insert central lines Remove central lines Insert transvenous pacemakers Set large bone fractures or dislocations Set small bone fractures or dislocations Code blue team leader Admit patient for physician Removal of foreign body from eye Perform joint aspirations Perform bone marrow aspirations & biopsy Provide intensive care on ambulance Perform laryngoscopy Perform tracheotomy Perform cricothyrotomy

4 REQUESTED PROCEDURES COLUMN 1 COLUMN 2 Perform nerve blocks Perform cryocautery, chem. cautery & electrocautery Evaluate & treat emergency room patients (within limits of ability of the care provider) Psychotherapy All nursing procedures Please list below other privileges requested: Mid-Level Practitioner Supervising Physician : : Secondary Supervising Physician :

5 WPPA Policy for Supervision of Mid-Level Practitioners WPPA has offered network membership to mid-level practitioners who are employed and supervised by a network physician. For purposes of this policy, mid-level practitioners include physician assistants (PA) and advanced practice registered nurses (APRN). All mid-level practitioners, regardless of membership status, must have written practice and prescription protocols that are approved by the supervising network physician. The practice and prescription protocols are to be in writing and detail the specific areas of responsibilities including procedures they may perform and classes of medications they may prescribe. Every physician who directs, supervises or delegates acts which constitute the practice of medicine and surgery to mid-level practitioners must: 1. Document and sign initial and periodic evaluations, to include annual review of practice protocols of the professional competency of the mid-level practitioner. 2. Annually review a sampling of patient records of WPPA patients treated by such practitioners and document such review in the patient record. 3. Provide for a substitute physician to direct and supervise such practitioners when the physician is temporarily absent or unavailable by telecommunication. 4. Direct, supervise or delegate to the mid-level practitioner only those acts which constitute the practice of medicine and surgery which the physician believes the mid-level practitioner is competent to perform. 5. Direct, supervise or delegate only those acts which are within the normal and customary specialty, competence, and practice of the physician. Mid-Level Practitioner Signature Supervising Physician Signature Secondary Supervising Physician Signature Rev 8/8/2014

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