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Pdf fillable capa form 2025

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The document is a notification form for Advanced Practice Registered Nurses (APRNs) in Kentucky to certify their prescriptive authority for controlled substances under the Collaborative Agreement for the Advanced Practice Registered Nurse Prescriptive Authority for Controlled Substances (CAPA-CS). It requires APRNs to confirm their national certification, good standing licensure, and includes sections for personal and practice information, as well as signatures from both the APRN and a collaborating physician.

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Click ‘Get Form’ to open the Pdf fillable capa form in the editor.
Begin by entering your last name in the designated field for 'APRN Last Name'. 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 name and the physician's first name in their respective fields, maintaining clear handwriting.
Provide your Kentucky APRN License number and the physician's license number in the appropriate sections.
Indicate your population focus and specialty. If applicable, enter your DEA number, remembering to attach a copy of your DEA license(s) from all states.
Both you and the physician must sign and date the form at the bottom. Ensure that all signatures are clear.
Finally, complete the practice name, address, city, state, zip code, and phone number fields before submitting.

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