Aprn protocol agreement 2026

1. Click ‘Get Form’ to open the aprn protocol agreement in the editor.
2. Begin by filling in the delegating physician's information. Enter their last name, first name, Georgia license number, and DEA registration number. If applicable, check the boxes indicating if they are a Georgia state, county, or city employee and provide proof of employment.
3. Next, specify the degree (MD or DO) and describe the practice area and specialty. Include the number of locations where the APRN will be practicing under this agreement.
4. Fill in the primary practice address for the APRN. Ensure all fields such as street number, street name, suite number (if any), city, state, phone number, fax number (optional), zip code, and county are accurately completed.
5. Provide details for the Advanced Practice Registered Nurse (APRN), including their DEA registration and RN number. Specify their type (e.g., Nurse Practitioner) and check if pending or will apply later.
6. Complete sections regarding license history for both the delegating physician and APRN. Include current license expiration dates and any restrictions on licenses.
7. Finally, ensure both parties sign and date the document. Enter required email addresses for communication purposes.

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