Controlled Substance Verification Form (CSVF)

jQuery UI Datepicker – Default functionality

Initial Update/Change

Please list below the name(s) of ALL of your supervising physicians listed on your collaborative agreement.

Authorized Schedules:
Please select Yes for all schedules for which you are approved to prescribe per the protocol with your supervising physician(s).
If there is an exception to your approved schedule, type the exception into the text box.
(ex: “All, except ABC Drug”)
Select No for the schedules your not approved for.

     
   
     
   
     
      

Attestation
I realize that this application is a legal document and by pressing the Submit button I am declaring under penalty of perjury under the laws of the State of Kansas that the information I have provided is true and correct to the best of my knowledge.
If all the above information is correct please press the Submit button .
Otherwise please go back and correct any information that is necessary.

Please Note: While a Collaborative Agreement is required to be on file with your employer, you do not need to send a copy of your agreement to KSBN.