"Application for Advanced Practice Registered Nurse (Aprn) Dispensing Privileges" - Nevada

Application for Advanced Practice Registered Nurse (Aprn) Dispensing Privileges is a legal document that was released by the Nevada State Board of Nursing - a government authority operating within Nevada.

Form Details:

  • Released on August 1, 2015;
  • The latest edition currently provided by the Nevada State Board of Nursing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nevada State Board of Nursing.

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Advanced Practice Registered Nurse (APRN)
Application for
Dispensing Privileges
Return to: Nevada State Board of Nursing, 5011 Meadowood Mall Way, Suite 300, Reno, NV 89502-6547
(888) 590-6726 | fax (775) 687-7707 | www.nevadanursingboard.org
Instructions
Submit complete application and examination fee of $150
Contact the Nevada State Board of Nursing (888) 590-6726 to schedule the dispensing examination.
Dispensing privileges are granted only after you have received prescribing privileges.
Please submit separate prescribing
.
privileges application if you have not already done so
Last Name
First Name
Middle Name
Social Security #
Date of Birth
Telephone #
Email Address
Mailing address (if you move, please notify the Board immediately, in writing, or via the Board’s website)
City
State
ZIP
Male
Female
Practice Location
(if you change practice locations, please notify the Board immediately, in writing)
Affirmation that current requirements of Nevada law will be met.
Yes
No
I affirm (swear) I will only dispense controlled substances, poisons, dangerous drugs or devices, which are
within the standard of my identified APRN role and population focus.
Affirmation
It is a violation of Nevada law to falsify this application, and sanctions may be imposed for fraud or misrepresentation.
Yes
No
I affirm (swear) that I have read this application and the statements made are true and correct.
If I have indicated a credit card number below, I authorize the application fee be charged to that credit card.
Signature
Date
If Paying By Credit Card, Please Complete
Visa
MasterCard
Discover
American Express
Exp. Date
Amount $150.00
Card number
Name on card
rev. 8/15
Advanced Practice Registered Nurse (APRN)
Application for
Dispensing Privileges
Return to: Nevada State Board of Nursing, 5011 Meadowood Mall Way, Suite 300, Reno, NV 89502-6547
(888) 590-6726 | fax (775) 687-7707 | www.nevadanursingboard.org
Instructions
Submit complete application and examination fee of $150
Contact the Nevada State Board of Nursing (888) 590-6726 to schedule the dispensing examination.
Dispensing privileges are granted only after you have received prescribing privileges.
Please submit separate prescribing
.
privileges application if you have not already done so
Last Name
First Name
Middle Name
Social Security #
Date of Birth
Telephone #
Email Address
Mailing address (if you move, please notify the Board immediately, in writing, or via the Board’s website)
City
State
ZIP
Male
Female
Practice Location
(if you change practice locations, please notify the Board immediately, in writing)
Affirmation that current requirements of Nevada law will be met.
Yes
No
I affirm (swear) I will only dispense controlled substances, poisons, dangerous drugs or devices, which are
within the standard of my identified APRN role and population focus.
Affirmation
It is a violation of Nevada law to falsify this application, and sanctions may be imposed for fraud or misrepresentation.
Yes
No
I affirm (swear) that I have read this application and the statements made are true and correct.
If I have indicated a credit card number below, I authorize the application fee be charged to that credit card.
Signature
Date
If Paying By Credit Card, Please Complete
Visa
MasterCard
Discover
American Express
Exp. Date
Amount $150.00
Card number
Name on card
rev. 8/15