Common Contracts

Prescriptive Authority Agreement

Prescriptive Authority Agreement • May 5th, 2020

• Contract Type
  Prescriptive Authority Agreement
• Filed
  May 5th, 2020

Name: License Number: Type of Practitioner:(select one)  Advanced practice registered nurse Physician assistant *DEA Permit #: DEA Exp. Date: *DPS Permit #: DPS Exp. Date: Name of Practice Site Address Type of Practice Site #1 Site #2 Site #3