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Click ‘Get Form’ to open the Pdf fillable capa form in our editor.
Begin by entering your last name in the designated field for the APRN. Ensure you print clearly for legibility.
Next, input the physician's last name in the corresponding field, also ensuring clarity.
Fill in both your first names in their respective fields, maintaining clear handwriting.
Provide your Kentucky APRN License number and the physician's license number accurately.
Indicate your population focus and specialty as required.
Enter your DEA number, remembering to attach a copy of your DEA license(s) from all states when submitting this form.
Both you and the physician must sign and date the form at the bottom before submission.
Finally, include the practice name, address, city, state, zip code, and phone number before returning it to the Kentucky Board of Nursing.

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