Illinois Advanced Practice Nurse Delegation of Prescriptive Authority for Controlled Substances (Delegation Statement) Instructions

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This form contains 21 fields organized into 6 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Advanced Practice Nurse — Identification & Licensing
Address (Street, City, State, ZIP) Textarea
Enter the APRN's complete mailing address including street address, city, state and ZIP code.
Advanced Practice Nurse Identification
Date of Birth - Month Text
Enter the month portion of the advanced practice nurse's date of birth.
Max length: 5 characters
Date of Birth - Year Text
Enter the year portion of the advanced practice nurse's date of birth.
Max length: 9 characters
Date of Birth - Day Text
Enter the day portion of the advanced practice nurse's date of birth.
Max length: 4 characters
SSN or ITIN Text
Enter the advanced practice nurse's Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN).
Max length: 27 characters
Advanced Practice Nurse Full Name Text
Enter the advanced practice nurse's name as last name, first name, and middle initial.
Maiden or Given Surname Text
Enter the advanced practice nurse's maiden name or given surname.
Max length: 56 characters
Advanced Practice Nurse License Numbers
Advanced Practice Nurse License Number Text
Enter the license number for the advanced practice nurse.
Max length: 31 characters
APN Controlled Substance Number Text
Enter the advanced practice nurse controlled substance number.
Max length: 53 characters
Collaborating Physician Details for Delegation
Collaborating Physician Printed Name Text
Enter the full printed name of the collaborating physician delegating prescriptive authority.
Max length: 51 characters
Collaborating Physician Illinois Controlled Substance Number Text
Enter the collaborating physician's Illinois controlled substance registration number without Physician CS Prefix
Collaborating Physician Illinois License Number Text
Enter the collaborating physician's Illinois medical license number, without Physician CS Prefix
Max length: 46 characters
Delegation Date Date
Enter the date on which prescriptive authority was delegated by the collaborating physician.
Collaborating Physician Business Street Address Text
Enter the collaborating physician's business street address.
Collaborating Physician Business City/State/ZIP Text
Enter the city, state, and ZIP code for the collaborating physician's business address.
Max length: 46 characters
Delegated Controlled Substance Schedules
Schedule II Checkbox
Check this box if the advanced practice nurse is being delegated authority to prescribe and/or dispense Schedule II controlled substances.
Schedule III Checkbox
Check this box if the advanced practice nurse is being delegated authority to prescribe and/or dispense Schedule III controlled substances.
Schedule V Checkbox
Check this box if the advanced practice nurse is being delegated authority to prescribe and/or dispense Schedule V controlled substances.
Schedule IV Checkbox
Check this box if the advanced practice nurse is being delegated authority to prescribe and/or dispense Schedule IV controlled substances.
Delegation Statement Parties
Collaborating Physician Name Text
Enter the full name of the collaborating physician who is delegating prescriptive authority.
Max length: 54 characters
Advanced Practice Nurse Name Text
Enter the full name of the advanced practice nurse receiving the delegated prescriptive authority.
Max length: 50 characters