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Holcomb Governor of Indiana  \nLindsay M. Hyer IPLA Executive Director  \nCover Sheet for Advanced Practice Registered Nurse Collaborative Agreement  \n1. Name of Facility:    \n2. Name of Advanced Practice Registered Nurse (APRN):    \n3. Indiana License Number (APRN or RN – if pending):    \n4. Type of Request (Check One): ☐ New Collaborative Agreement ☐ Additional Collaborative Agreement  \n5. For changes to existing Collaborative Agreements or CSR practice location/license status, please choose from one of the options below and include a detailed cover letter on letterhead (clarifying exactly which physicians you are adding/deleting/keeping, which locations you are adding/deleting/keeping and the date the changes should take effect):  \n☐ Add Collaborator to existing Agreement:  ☐ Delete Collaborator from existing Agreement: ☐ Add location(s) to the existing Agreement:    \n______________________________________________________________________________________________  \n☐ Delete location(s) from existing Agreement:    \n______________________________________________________________________________________________  \n☐ Cancel Current CSR at practice location:    \n______________________________________________________________________________________________  \n** Note: CSR will be switched to Current/Not Practicing status as a result  \n☐ Request to Update CSR with a new practice location:    \n______________________________________________________________________________________________  \n☐ Other (please include cover letter if need):    \n* Please Note: If you do not have a Controlled Substances Registration (CSR) and intend to administer and dispense controlled substances, you must apply for CSR. Please visit our website at [http://www.in.gov/pla/](http://www.in.gov/pla/); under the Menu, navigate to Profession >> Nursing Board >> Licensing Information >> Controlled Substances Registration.**","cbCaiveSVrrag5mg","https://ap.wps.com/l/cbCaiveSVrrag5mg","pdf",473822,"English","# Request Cover Sheet Details\n## Facility and APRN Information\n## Type of Request and Change Options\n## Controlled Substances Registration Notice","[{\"question\":\"What information does the cover sheet request for an APRN collaborative agreement?\",\"answer\":\"It asks for the name of the facility, the name of the Advanced Practice Registered Nurse (APRN), and the Indiana license number (if available).\"},{\"question\":\"Which types of requests can be selected on the form?\",\"answer\":\"The form supports new collaborative agreements and additional collaborative agreements, along with options for adding or deleting collaborators, adding or deleting locations, canceling CSR at a location, updating CSR with a new location, or choosing other requests.\"},{\"question\":\"When is a detailed cover letter required and what should it clarify?\",\"answer\":\"For changes to existing collaborative agreements or CSR practice location/status, the form requires a detailed cover letter on letterhead clarifying which physicians are added, deleted, or kept, which locations are added, deleted, or kept, and the effective date of the changes.\"}]","Cover Sheet for Advanced Practice Registered Nurse Collaborative Agreement | PDF",1789288331]