Section 3100.85  Application for Mid-Level Practitioner Controlled Substances License

a)         An individual applicant for a mid-level practitioner controlled substances license shall file an application on forms provided by the Department.  The application shall include:

1)         The physician assistant or advanced practice nurse license number.  The license shall be active and in good standing;

2)         The license number and controlled substances license number of the delegating physician;

3)         A notice of delegation of prescriptive authority signed by the physician indicating the schedule of controlled substances that the practitioner may dispense or prescribe.  A separate notice of prescriptive authority shall be submitted by each supervising or collaborating physician; and

4)         The required fee.

b)         Pursuant to the Humane Euthanasia in Animal Shelters Act rules (68 Ill. Adm. Code 1248), a euthanasia agency applicant for a mid-level practitioner controlled substances license shall file an application on forms provided by the Department.  The application shall include:

1)         The euthanasia agency license number.  The license shall be active and in good standing;

2)         The required fee as stated in Section 3100.30.

(Source:  Amended at 28 Ill. Reg. 9633, effective June 28, 2004)