APPLICATION: ADD NEW COLLABORATION– NON-ALABAMA RN … · 2020. 7. 15. · Application: Add New Collaboration – Non-Alabama MSL RN 2 of 4 Approved: July 2020 YES NO STANDARD 1

1 of 4 Application: Add New Collaboration – Non-Alabama MSL RN Approved: July 2020

APPLICATION: ADD NEW COLLABORATION – NON-ALABAMA RN MSL

Last___________________________ First__________________ Middle_______________

DOB: _________________ SSN: ___________________________

AL CRNP/CNM #: 3-______________ Telephone: ______________________

Email: ______________________________________________

Return completed application, with all required documentation and payment, to:

PO Box 303900, Montgomery, AL 36130

Please Note: In addition to this completed application, the applicant must submit an

application fee in the amount of $75.00. Payment may be made by cashier’s check, business

check, money order, certified check, or personal check, provided that the licensed nurse’s

name is imprinted on the check. Please note: the Board cannot accept personal checks

drawn on out of state banks. [ABN Administrative Code § 610-X-4-.14]

:

Instructions: Additional sheets may be attached, if necessary. Incomplete applications will not be considered by the Board.


YES NO STANDARD 1. Excluding minor traffic violations*, have you ever: (check all that

apply)Been convicted of any crime in any state, municipality, territory, or country? Entered a plea of guilty to any crime in any state, municipality, territory, or country? Entered a plea of nolo contendere or no contest for any crime in any state, municipality, territory, or country? Received deferred prosecution or adjudication for any crime in any state, municipality, territory, or country? Had judgment withheld for any crime in any state, municipality, territory, or country? Received pretrial diversion for any crime in any state, municipality, territory, or country? Received any other alternative sentencing, supervision, or diversion program for any crime in any state, municipality, territory, or country? Stipulated to a prima facie case against you for any crime in any state, municipality, territory, or country? Pleaded not guilty by reason of insanity or mental defect to any crime in any state, municipality, territory, or country?

*Any crime related to driving while impaired or while under the influence of any substanceis not a "minor traffic violation."

2. In the past three years, or since your last completion of anyapplication for nursing licensure, have you abused alcohol, drugs(whether legal or illegal, prescribed or unauthorized), and/or otherchemical substances or received treatment or been recommendedfor treatment for dependency to alcohol, drugs (whether legal orillegal, prescribed or unauthorized), and/or other chemical substances?

3. In the past three years, or since your last completion of anyapplication for nursing licensure, have you had, or do you now have,a physical or mental health problem that may impair your ability toprovide safe nursing care?

4. Has the licensing authority of any state, territory, or country denied,revoked, suspended, reprimanded, fined, accepted your surrenderof, restricted, limited, placed on probation, or in any other waydisciplined your nursing and/or any other occupational license,registration, certification, or approval?

5. Is the Board of Nursing or other licensing authority of any state,territory, or country currently investigating you?

6. Is disciplinary action pending against you with the Board of Nursingor other licensing authority of any state, territory, or country?

7. Are you currently a participant in any alternative program (anondisciplinary monitoring program approved by a licensing board)?

8. Are you now, or have you ever been, placed on a state and/orfederal abuse registry or placed on the Office of Inspector Generalexclusion list?

9. Has any branch of the armed services ever administrativelydischarged you with any characterization of service other than“Honorable” and/or court-martialed you?

Regulatory Questions

CRNP Name:

RN License#: 3-

Application: Add New Collaboration – Non-Alabama MSL RN Approved: July 2020

3 of 4

New Collaboration

Collaborating Physician/Primary Practice Site

Physician Name AL License# Name of Practice

Specialty Physical Address

Phone Email Address

How Much Will the CRNP/CNM Work? Full Time Part Time Flex/PRN

All Practice Sites of CRNP/CNM

Name Complete Address and Phone# (County-only for Home Visits)

Covering Physician(s)

Physician Name AL License# Physical Address

Phone: Email:

Physician Name AL License# Physical Address

Phone: Email: Physician Name AL License# Physical Address

Phone: Email: Physician Name AL License# Physical Address

Phone: Email: Protocols/Skills/Prescriptive Authority

Protocols

Standard Protocol

Critical Care Specialty Protocol

Orthopedic Specialty Protocol

Otolaryngology Specialty Protocol

Critical Care ADVANCED Protocol

Flex/PRN

Limited Protocol – CPE

Limited Protocol – LTCF

Prescriptive Authority No Rx Standard Formulary

Hours Per Week:

Add Additional Skills Select skills based on your national certification.

Note: If your certification does not appear in the table below, no additional skills are available for that certification.

National Certification Skills (Choose skills for your national certification only). Ultra-Violet Therapy, Maintenance and Direction

Chemical Peel: Superficial Depth

Trigger Point Injection Below T12

Percutaneous Tibial Nerve Stimulation

Adult NP

Ultra-Violet Therapy, Maintenance and Direction



Percutaneous Tibial Nerve Stimulation

Insertion of Central Line, Internal Jugular

Family NP




Subdermal Contraceptive Implant, insertion and removal

Gerontological NP




Neonatal NP Insertion of Central Line, Internal Jugular

Pediatric NP

Insertion of Central Line, Internal Jugular


Epicardial Pacing Wires, removal

Insertion of Intrauterine Devices

Women’s Health NP





CNM





OB Limited Ultrasound

Circumcision

Attestation: I hereby certify that the information contained in this application is true and correct, to the best of my knowledge and belief.

Signature of Applicant: ____________________________________ Date: ______________


Acute Care NP

CRNP Name: ______________________ RN License#: 3- ____________

Documents

APPLICATION: ADD NEW COLLABORATION– NON-ALABAMA RN … · 2020. 7. 15. · Application: Add New Collaboration – Non-Alabama MSL RN 2 of 4 Approved: July 2020 YES NO STANDARD 1