List the name, SSN, and address of any immediate family member who is authorized under Kentucky Law or any other states’ professional boards to prescribe drugs, medicine, medical devices, or medical equipment in accordance with KRS 205.8477.
Name
Enter the First and Last Name. Initials are not accepted in this field
Credential (M.D., etc) – Select one of the Credentials from the drop down box below
APRN (Advanced Practice Registered Nurse Practitioner)
CRNA (Certified Registered Nurse Anesthetist)
DDS (Doctor of Dental Surgery)
DMD (Dentist)
DO (Doctor of Osteopathy)
DPM (Podiatrist)
MD (Medical Doctor)
OD (Optometrist)
PA (Physician Assistant)
DOB
Enter the Date of Birth
Age cannot be greater than 100 years of age
SSN
Enter the Social Security Number
Address
Enter the address information in this field
City
Enter the city for the applicable address
State
State defaults to Kentucky but is editable
Select the state from the drop down box
Zip Code
Enter the zip code for the applicable address entered
Zip+4
If known, enter the +4 Zip code
If fields are entered then N/A is checked, the data entered will be cleared
Special Characters:
The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:
For First Name, Business Name, Other name (if any): | + \ '
For Last Name field: | + \ ', and numbers are not allowed
For Comment Boxes: < > ^ ~ ` + | \ / ¬ £
For Address fields: | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _
If you copy and paste an excluded special character, an error message will display after clicking Save & Next
Remove excluded characters from pasted information or uploaded text in the document
Save & Next:
When finished, click Save & Next to save the information and proceed to the next page
Click Back to go to the previous screen without saving
Click Exit to return to the dashboard without saving
Note that if the information is not saved, you will lose the data on the current page