1) Classification: (Select one) RN/NP RN/NM RN/PC RN/NA PA 2) Massachusetts Board of Registration License No.:

Transcription

1 Commonwealth of Massachusetts, Department of Public Health, Drug Control Program 99 Chauncy Street, Boston, MA Telephone Fax Application for Massachusetts Controlled Substances Registration for Advanced Practice Nurses and Physician Assistants in Accordance with the Controlled Substances Act, M.G.L. Chapter 94C Please be sure to: Mail completed application, sides 1 and 2, along with required documentation; Include a copy of the applicant s current Massachusetts Board of Registration license for advanced practice nurse or physician assistant; Include copies of each current supervising physician(s) Massachusetts Controlled Substances Registration and federal DEA registration; Have the applicant sign (not initial) and date the form at the bottom of second page.; Have the supervising physician sign (not initial) and date the form in the Supervising Physician Information section (Does not apply to nurse mid-wives.); Enclose check or money order for $ made payable to Commonwealth of Massachusetts ; Incomplete applications will be returned and will cause a delay in receiving the MCSR. Only send copies of licenses and registrations. Do not send originals. They will not be returned. For further information visit the DCP website at Application Type: (Please select one) New Renewal In the boxes below enter the requested information. 1) Classification: (Select one) RN/NP RN/NM RN/PC RN/NA PA 2) Massachusetts Board of Registration License No.: 3) DEA Controlled Substance Registration No. (If issued/ possessed): 4) Name: First: Middle: Last: Suffix: (e.g. Jr., Sr., II, III) 5) Applicant Business Address: Applications with a P.O. Box number and no street address cannot be processed. Out-of-state addresses require a letter of explanation. Registrations are site specific. List every business location where you practice. If you change or add a business address during the year, you are required to notify this program by submitting an amended information form. Business/Facility Name (and Department if applicable): Street: City: State: ZIP: 6) Mailing Address: Check here if same as the Business Address Facility Name and Department (if applicable): Street: City: State: ZIP: 7) Business Telephone No.: 8) Applicant s address (must be specific to applicant, cannot be accessed by other persons): 9) Drug Schedules requested: Select all that apply: II III IV V VI Schedule VI includes all prescription drugs not in Schedules II - V. Only Schedules that are checked can be authorized. 10) (See the Code List) Corresponds with Question 17).: 11) Virtual Gateway Username (If possessed, see instructions): 12) Birth Month and Day [MMDD] (Do not include year): 13) Compose a four digit PIN for MA Online PMP (No letters or other non-numeric characters): Advanced Practice NP PA New or Renewal Application Page 1 of 5

2 14) Social Security No.: (Required by M.G.L. c. 30A, s. 13A) 15) Have you ever been convicted of any violation of State or Federal law relating to the manufacture, possession, distribution or dispensing of controlled substances? Yes * No 16) Has any previous professional license or registration held by you under any name or corporate name or legal entity been surrendered, revoked, suspended or denied or is such action pending? Yes * No * A Yes to Question No. 15) or No. 16), requires a letter of explanation attached to this form. Supervising Physician Information: Not required for Nurse Midwives. 17) The following Supervising Physician s Information must be completed by each physician who supervises your practice. The supervising physician is the individual with whom you, the applicant, have developed and signed mutually agreed upon guidelines. If you practice in more than one medical specialty or in more than one setting (e.g., more than one employer), you must complete this section for each supervising physician for each medical specialty and/or setting. You may make photocopies of this page as necessary. Name of Supervising Physician: Telephone No. ( area code ) Business Address: Board of Medicine License No.: DEA Controlled Substance Registration No.: Massachusetts Controlled Substances Registration No.: Medical : Are there written guidelines in place? Yes No Written guidelines are required for Advanced Practice Nurses and for Physician Assistants. Applications checked No will be returned. Signature of Supervising Physician: Date Applicant please sign and date below I hereby certify that (1) the information on this application is true to the best of my knowledge; (2) I possess written guidelines that were mutually developed, agreed upon, and signed by my supervising physician and me; and (3) I will comply with the laws of the Commonwealth of Massachusetts and all applicable rules and regulations of the Department of Public Health and either the Board of Registration in Nursing or the Board of Registration of Physician Assistants, whichever is applicable. I also certify, in accordance with M.G.L. c. 62C, section 49A, that I have to the best of my knowledge and belief complied with all laws of the commonwealth relating to taxes, reporting of employees and contractors, and withholding and remitting of child support. I also certify that I have read and agree to the TERMS AND CONDITIONS FOR PRESCRIBER AND DISPENSER USE OF THE MASSACHUSETTS ONLINE PRESCRIPTION MONITORING PROGRAM. I understand that the Terms and Conditions may be revised from time to time, that I will be notified of any change and that my continued use of the MA Online PMP after such notice shall constitute my acceptance of the new Terms and Conditions. Signed under the pains and penalties of perjury. Signature of applicant Date Advanced Practice NP PA New or Renewal Application Page 2 of 5

3 Terms and Conditions for Prescriber and Dispenser Use of the Massachusetts Online Prescription Monitoring Program By logging in to and using the Massachusetts Online Prescription Monitoring Program ( MA Online PMP ), you agree to abide by the requirements governing the Prescription Monitoring Program at 105 CMR and any other applicable requirements, including, but not necessarily limited to: 1) You attest to the following: a) You are a duly licensed practitioner, pharmacist or other licensed health care professional authorized to prescribe or dispense controlled substances in the Commonwealth of Massachusetts; b) You are duly registered, or in the process of registering, with the Massachusetts Department of Public Health, Drug Control Program, to prescribe controlled substances. You also agree to promptly notify the Department of any change or proposed change in licensure or registration status; c) You are duly enrolled to use the MA Online PMP and that you have not provided nor will provide your login credentials (i.e., username, password, Personal Identification Number or any other security information) to anyone else. You are responsible for promptly notifying the Drug Control Program of any compromise of your login credentials or changes to your enrollment information (e.g., changes to name, business or address, license or registration number) or prescriptive privileges; and d) Your use of the MA Online PMP is for the purpose of preventing the prescribing and/or dispensing of controlled substances to the same individual from multiple sources or the unlawful diversion of controlled substances. You may not request the prescription history for anyone other than your patient or for a patient encounter. 2) You acknowledge that you understand the following: a) The Department of Public Health does not guarantee the accuracy or completeness of the information contained in the database. There may be multiple persons with the same name in the database, so you should use other information, such as date of birth and address, to distinguish your patient from others with the same name; b) You may use or disclose information obtained from the MA Online PMP, including reports generated from the database, only as permitted by applicable state and federal laws governing confidentiality and security of personal/patient information, including, if applicable, the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA); c) You must promptly notify the Department of any potential violation of confidentiality or use of the data in a manner contrary to the regulations or applicable professional standards; d) Usage of the MA Online PMP is recorded and monitored and that your right to use the system may be revoked at any time at the discretion of the Department. e) Your controlled substances registration may be suspended or terminated in accordance with 105 CMR (L)(1), and that a referral may be made for criminal prosecution or disciplinary action by your licensing board, for the following: i. a request, use or disclosure of data that involves a willful failure to comply with the standards in 105 CMR for request, transmission or disclosure of data; ii. a failure to reasonably protect data in accordance with the requirements of 105 CMR or other applicable state or federal law; or iii. an attempt to obtain data through fraud or deceit; f) Data is being provided for the purpose of safe prescribing and dispensing, including assessing or preventing the possibility of drug abuse or diversion, but does not require you to take action that you believe to be contrary to the best interests of your patient; and g) The Department may revise these Terms and Conditions from time to time. You will be notified of any change and your continued use of the MA Online PMP after such notice shall constitute your acceptance of the new Terms and Conditions. Advanced Practice NP PA New or Renewal Application Page 3 of 5

4 Item by Item MCSR Application Form Instructions 1) Select your professional degree. 2) Fill in your the Board of Registration number. 3) Fill in your personal DEA number. An existing out-of-state DEA registration is acceptable for new applicants. However for renewed applicants a DEA registration with a Massachusetts business address is required. There are limitted exceptions to this rule. Please provide a letter of explanation if you provide an out-of-state DEA number. 4) Include your complete middle name (no initials), and a suffix, if applicable. 5) Fill in your business address. 6) Fill in your mailing address. If you do not use fill in a mailing address, all mailings will go to your business address. 7) Fill in the phone number at which you can be reached. Please be mindful that this phone number would be used should DCP need to contact you or should prescribers or pharmacists need to consult with you regarding MA Online PMP prescription histories. 8) Please provide an address that you monitor frequently. You will receive status updates and instructions on using the MA Online PMP via the address you provide on the enrollment form. The address will also be used to send updates regarding the MA Online PMP Terms and Conditions, alerts and MA Online PMP enrollment renewal notices. 9) Check off the drug schedule privileges you are requesting. If you check of a higher schedule and leave any lower schedules unchecked, you will be granted privileges for the lower schedule also. For example, if you check off only Schedule II, you will also be granted privileges for Schedules III VI. 10) Enter the relevant Code(s) found on the Code List. If you do not see a code that closely identifies your specialty, you may write in your specialty. Certified Nurse Midwives enter code "OBGN", meaning Obstetrics & Gynecology. Physician Assistants and other Advance Practice Nurses enter the specialties that reflects in the mutually developed and agreed upon prescriptive practice guidelines with their supervising physician(s). Pharmacists enter the specialties that most closely reflect the managed disease state(s) in the CDTM collaborative practice agreement with their supervising physicians(s). 11) If you are not already an end user of the Virtual Gateway (VG), leave this box blank. The MA Online PMP is hosted in the VG, which is an internet portal operated by the Massachusetts Executive Office of Health and Human Services (EOHHS) to provide the general public, medical providers, community-based organizations and EOHHS staff with a single resource for health and human services applications. If you are already an end user of the VG because of another application, please provide your VG username. A preexisting VG end user will continue to use the same username and password. 12) Enter your birth month and day. You may omit the year. This information is required by the VG. 13) The four-digit PIN you create is a necessary identifier should you need to have your password reset for the MA Online PMP. Please be sure to save the number in a location that you can easily retrieve it from if needed. 14) Enter your social security number. 15) Check the Yes or the No box. If checking the Yes box, include a letter of explanation. 16) Check the Yes or the No box. If checking the Yes box, include a letter of explanation. 17) Enter the information with respect to the supervising physician(s) and have the supervising physician s sign and date this section. Attach a separate sheet with this section for each additional supervising physician. Nurse mid-wives are exempt from entering the supervising physician section. If you have questions, you may call the Drug Control Program at For further information visit our Web site at Advanced Practice NP PA New or Renewal Application Page 4 of 5

5 Code List Code Code Addiction Medicine... ADXN Allergy... ALGY Anesthesiology... ANTH Bariatrics - Weight Control... BAWT Cardiology... CDGY Dermatology... DERM Emergency Medicine... EMRG Endocrinology... ENDM Family Medicine... FAMM Gastroenterology... GAST Geriatrics... GRTC Hematology... HEMT Hospice - Palliative Care... HSPC Immunology... IMMN Infectious Disease... INFD Hospitalist... INTH Internal Medicine... INTM Neurology... NRAA Neurology - Pediatric... NRCH Obstetrics & Gynecology... OBGN Oncology... ONCG Ophthalmology... OPHY Orthopedics... ORTH Osteopathic Medicine... OSTM Otolaryngology... OTOL Pain Medicine... PAIN Psychiatry - Adult... PCAD Psychiatry - Child & Adolescent... PCCA Psychiatry - Geriatric... PCGR Pediatrics... PEAA Pediatrics - Palliative Care... PEHP Pediatrics - Surgery... PESG Podiatry - Diabetics... PGDB Podiatry - Surgery... PGSR Physical Med & Rehab... PHYM Pulmonology... PLDS Podiatry - General Practice... PRAA Psychopharmacology... PSPM Radiology... RDOL Rheumatology... RHMA Surgery - General... SGAA Surgery - Orthopedic... SGOR Surgery - Plastic... SGPL Sports Medicine... SPMD Toxicology... TXGY Urology... URGY Vascular Disease... VSDS Questions continue on the next page Rev