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      Additional State Requirements Prior to Launch

      The post-signature process to ensure your agreement is filed with the State Boards.

       


      Once signed and executed, you will receive a copy of your agreement through email as well as in your Zivian Account. 


      In some instances, you may be required to complete a few additional steps prior to the agreement being active. Those requirements differ state by state. In most cases, you must submit either a copy of the agreement or attest to having a valid agreement with the State Medical Board. Once completed, all proof of approval, attestation or submissions must be provided to Zivian via our secure Document Portal: Submit Documents Here 


      States that Require Approval

      • Alabama
      • Nevada
      • North Carolina

      States that Require Additional Submissions

      • Texas
      • Kentucky
      • Georgia
      • Pennsylvania
      • Indiana
      • Florida
      • Tennessee

      Be sure to review and ensure you complete all required steps for the states where our agreement is active. Failure to submit additional documents may result in the voiding of an agreement or the Board rejecting your application. 


      To view the specific state requirements, see the State Submission Process and Guidelines section at the end of this document. 




      State Submission Process and Guidelines


      States with additional Submission Requirements - No formal Approval Required


      Texas


      APCs must following the process below as its an APC initiated request:

      1. Log into your existing TMB portal account or create a new one.
      2. Create a “New Supervision/Delegation”
      3. Enter your collaborating physician’s information and click “Save” to attest to the relationship. This will create an “Incomplete Relationship” record.
      4. Your collaborating physician will then select this record on their own TMB portal account and attest to your relationship. This will create your final collaborative relationship in the Portal.

      If APCs are prescribing Schedule II controlled substances the physician will need to submit the prescription on behalf of the provider.


      Kentucky


      In order to be granted prescriptive authority in Kentucky, you are required to submit completed CAPA-CS and CAPA-NS Notification forms to the Board of Nursing via the Board of Nursing Nurse Portal.


      Georgia


      Georgia requires that you file a Collaborative Agreement with the Composite Medical Board to be granted prescriptive authority. The GCMB provides a checklist for filing the agreements found here.

      1. The GCMB requires the submission be mailed to: 2 MLK Jr. Drive SE, East Tower, 11th Floor, Atlanta, GA 30334
      2. You will need to submit a license verification to the GCMB that includes a copy of your current APRN license, copy of national certification (wallet card or letter with expiration date), and a copy of specialty training (if applicable).
      3. The submission will need to include the Registration Form, Collaboration Agreement, Protocol Agreement, License Verification, and a $150 fee (payable to GCMB).

      Mississippi


      The physician licensee must submit the requested documentation via the online licensure gateway <https://gateway.msbml.ms.gov/>. If a physician wishes to collaborate under the Primary Care Extended Mileage language, the physician must submit a letter via the gateway identifying the name(s), address(es), and license numbers of any collaborative APRNs whose collaboration is the subject of the letter, and which also affirmatively states the physician has read the regulations and meets the extended mileage requirements as stated.



      Pennsylvania


      Pennsylvania requires that you file a Prescriptive Authority Collaborative Agreement form and provide them with your Collaboration Agreement. Instructions for this process can be found at the following link: Instructions. 


      The Prescriptive Authority Collaborative Agreement Form is available when you log in to your Pennsylvania Licensing System account. 


      Indiana


      In order to prescribe independently, APRNs must submit an Advanced Practice Registered Nurse application. A detailed list of the requirements can be found at this link: APRN Application Requirements

      - this application will need to be submitted to the Professional Licensing Agency. The Indiana Professional Licensing Agency site can be found at this link: Professional Licensing Agency. 



      Florida


      Physicians must facilitate and submit a copy of the signed agreement along with the Protocol form found APRN Protocol Form. 


      This must be filed within 30 days of entering into the relationship, protocol, or orders. Forms must be mailed to:


      Department of Health

      Division of Medical Quality Assurance

      Board of Medicine

      4052 Bald Cypress Way, Bin C03

      Tallahassee, FL 32399-3253



      Tennessee


      Only required when prescriptive authority is delegated. Complete the Notice and Formulary Form. Once completed, it must be mailed to:


      Tennessee Board of Nursing 

      665 Mainstream Drive 

      Nashville, TN 37243


      Update the Controlled Substance Monitoring Database (CSMD):

      • Nurse practitioners should enter your driver’s license number to identify you as their supervisor.
      • You'll receive a notification when you log in to CSMD, indicating pending relationships.
      • On the "My Account" screen, approve pending relationships.
      • If the supervisory relationship ends, revoke it from the "My Account" page in CSMD.


      • The following states require approval before practicing: 

      Alabama


      Alabama requires that the Physician and Provider file the agreement and additional documentation to the Board of Medicine and Board of Nursing. Zivian will share the template Quality Assurance Plan that can be adjusted and updated between the physician and practitioner if deemed necessary. 


      1. The Physician will need to complete the Commencement Form at this link. This will include listing all collaborations they are in including those outside of Alabama. The hours must be less than 360 hours per a week for all collaborations. This includes a $200 fee to submit this form.
      2. The Provider will need to file a Standard Protocol based on their specialty as well as a Quality Assurance plan with the collaborating Physician. These documents can be submitted at this link. Both of these steps will need to be done to have the agreement approved. 

      Zivian does not help with the writing of these two documents.


      North Carolina

      Nurse Practitioners in North Carolina must submit an "Approval to Practice" application, under a collaborative practice agreement with a supervising physician. This applies to those seeking approval to practice for the first time or with existing Nurse Practitioner registration.

      Application Fees:

      • $100.00 (Per Physician for Nurse Practitioner in a Paid Position) 
      • $20.00 (Per Physician for Nurse Practitioner in a Volunteer Position)

      Nurse Practitioners cannot practice until receiving approval from the Board of Nursing. Approval documents will be emailed upon final approval.

      If Nurse Practitioners haven't submitted their Nurse Practitioner Registration, they can file both forms together:

      • $25.00 (Registration)
      • Plus the respective physician fees mentioned above.

      The North Carolina Board of Nursing and the North Carolina Medical Board jointly review and approve initial Approval to Practice applications.

      Practice should only commence after receiving approval, with notification sent via email.

      For more details, visit: Nurse Practitioner | North Carolina Board of Nursing


      Nevada


      In Nevada, APRNs and their collaborating physicians are required to mail a notification of their collaboration to the Board and wait for approval. After your collaboration is executed Zivian will share the document you must notarize and submit to the state board. 


      A copy of this form can be found here: Notification to Nevada State Board on Collaboration Agreement


      South Carolina


      In South Carolina, please review form and instructions here: https://llr.sc.gov/nurse/pdf/Prescriptive_Authority_App_Elec_Inst.pdf 


      You will need the following documents to upload to your electronic application:

      • Evidence of required educational contact hours as indicated in Requirements.
      • Completed New Employment/ Change of Practice/ Prescriptive Authority Form (Form is in Instructions and Forms package), if applicable
      • Copy of current state-issued license verification or a current DEA registration that reflects current prescriptive authority licensure, if applicable.

      We recommend following the below application sequence for prescriptive authority:


      1. Obtain a SC APRN license.
      2. Once employed and if desired, apply for prescriptive authority. You will need the pharmacology hours and the collaborating Physician.
      3. Once prescriptive authority is granted and if you desire a DEA license, apply for the Controlled Substance Registry through SC DHEC.
      4. Apply for DEA license.