Protocol Form For Prescription Of Schedule Ii Controlled Substance Drugs printable pdf download

Protocol Form For Prescription Of Schedule Ii Controlled Substance Drugs

Clinic or Physician Letterhead

Date:

Nevada State Board of Nursing

5011 Meadowood Mall Way, Suite 300

Reno, NV 89502-6547

Protocol for Prescription of Schedule II Controlled Substance Drugs

Dear Board:

Per NRS 632.237 Subsection 2(b)-3(b): ”An advanced practice registered nurse may:

(b) If authorized pursuant to

NRS 639.2351

and subject to the limitations set forth in subsection 3,

prescribe controlled substances, poisons, dangerous drugs and devices.

3. An advanced practice registered nurse who is authorized to prescribe controlled substances,

poisons, dangerous drugs and devices pursuant to

NRS 639.2351

shall not prescribe a controlled

substance listed in schedule II unless:

(a) The advanced practice registered nurse has at least 2 years or 2,000 hours of clinical experience;

(b) The controlled substance is prescribed pursuant to a protocol approved by a collaborating

physician.”

Please be advised that (Name) APRN, Nevada License Number _______ will begin employment with -

______(physician)______________ on _________(date)__________________.

Dr. (Physican Name, License Number) is a (Family Practice, etc MD/DO/DPM etc…)

(Physician Name) has agreed to be the collaborating physician for prescribing Schedule II Controlled

Substance Drugs for (Name APRN, FNP) per NRS 639.2351 and the following protocol.

The signatures below affirm that:

•

Prior to prescribing Schedule II Controlled Substances, the advanced practice registered nurse

(APRN) shall obtain a Controlled Substance Registration Certification through the U.S. Drug

Enforcement Agency (DEA).

•

Prescriptions issued by the advanced practice registered nurse (APRN) for Schedule II Controlled

Substances classified by the Drug Enforcement Agency

( ) shall be limited to a seventy-two (72) hour supply

without refill.

•

The parties agree that the advanced practice registered nurse (APRN) will have full authority to

prescribe any medication in the Class II category.

•

The parties further agree that the APRN will consult with the physician in a manner and on a

schedule determined by the parties.

Protocol Form For Prescription Of Schedule Ii Controlled Substance Drugs