SB249: Bill Text

Licensure of advanced practice registered nurses

Under current law, a person who wishes to practice professional nursing must be licensed by the Board of Nursing as a registered nurse (RN). This bill creates an additional system of licensure for advanced practice registered nurses (APRNs), to be administered by the board. Under the bill, in order to apply for an APRN license, a person must 1) hold, or concurrently apply for, an RN license; 2) have completed an accredited graduate-level or postgraduate-level education program preparing the person to practice as an APRN in one of four recognized roles and hold a current national certification approved by the board; 3) possess malpractice liability insurance in an amount determined as provided in the bill; 4) pay a fee determined by the Department of Safety and Professional Services; and 5) satisfy certain other criteria specified in the bill. The bill also allows a person who has not completed an accredited education program described above to receive an APRN license if the person 1) on January 1, 2017, was both licensed as an RN in Wisconsin and practicing in one of the four recognized roles; and 2) satisfies additional practice or education criteria established by the board. The four recognized roles, as defined in the bill, are 1) certified nurse-midwife; 2) certified registered nurse anesthetist; 3) clinical nurse specialist; and 4) nurse practitioner. The bill also requires the board, upon granting a person an APRN license, to also grant the person one or more specialty designations corresponding to the recognized role or roles for which the person qualifies.

The holder of an APRN license may append the title “A.P.R.N." to his or her name, as well as a title corresponding to whichever specialty designations that the person possesses. The bill prohibits any person from using the title “A.P.R.N.," and from otherwise indicating that he or she is an APRN, unless the person is licensed by the board as an APRN. The bill also prohibits the use of titles and abbreviations corresponding to a recognized role unless the person has a specialty designation for that role. However, the bill allows an APRN to delegate a task or order to another clinically trained health care worker if the task or order is within the scope of the APRN's practice, the APRN is competent to perform the task or issue the order, and the APRN has reasonable evidence that the health care worker is minimally competent to perform the task or issue the order under the circumstances. The bill requires an APRN to adhere to professional standards when managing situations that are beyond the advanced practice nurse's expertise.

Under the bill, when an APRN renews his or her APRN license, the board must grant the person the renewal of both the person's RN license and the person's APRN license. The bill requires all APRNs to complete continuing education requirements each biennium in clinical pharmacology or therapeutics relevant to the APRN's area of practice and to satisfy certain other requirements when renewing a license.

Practice of nurse-midwifery

This bill repeals licensure and practice requirements specific to nurse-midwives and the practice of nurse-midwifery, including specific requirements to practice with an obstetrician. Under the bill, “certified nurse-midwife" is one of the four recognized roles for APRNs, and a person who practices nurse-midwifery under current law who satisfies the APRN licensure requirements may apply for and receive an APRN license and a certified nurse-midwife specialty designation, except that the bill also requires that a person applying for a certified nurse-midwife specialty designation be certified by a national certifying body approved by the board.

Advanced practice registered nurse prescribers

Under current law, a person licensed as an RN may apply to the board for a certificate to issue prescription orders if the person meets certain requirements established by the board. An RN holding a certificate is subject to various practice requirements and limitations established by the board and must possess malpractice liability insurance in an amount determined by the board.

The bill eliminates certificates to issue prescription orders and replaces them with permits to issue prescription orders. The bill allows the holder of an APRN license to apply for a permit or for an applicant for an APRN license to apply for a permit concurrently with his or her APRN license application. The bill requires the board to establish the appropriate education, training, or experience requirements that a registered nurse must satisfy to be granted a permit to issue prescription orders. As under current law, an APRN holding a permit is subject to various practice requirements and limitations established by the board.

The bill repeals a provision concerning the ability of advanced practice nurses who are certified to issue prescription orders and who are required to work in collaboration with or under the supervision of a physician to obtain and practice under a federal waiver to dispense narcotic drugs to individuals for addiction treatment.

Other changes

The bill makes numerous other changes throughout the statutes relating to APRNs and APRN prescribers, including various terminology changes and technical changes relating to the Nurse Licensure Compact.

For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB249,1 Section 1 . 14.87 (title) of the statutes is amended to read:

SB249,4,2 14.87 (title) Enhanced nurse Nurse licensure compact.

SB249,2 Section 2 . 29.193 (1m) (a) 2. (intro.) of the statutes is amended to read:

SB249,4,8 29.193 (1m) (a) 2. (intro.) Has a permanent substantial loss of function in one or both arms or one or both hands and fails to meet the minimum standards of any one of the following standard tests, administered under the direction of a licensed physician, a licensed physician assistant, a licensed chiropractor, or a certified licensed advanced practice registered nurse prescriber:

SB249,3 Section 3. 29.193 (2) (b) 2. of the statutes is amended to read:

SB249,5,7 29.193 (2) (b) 2. An applicant shall submit an application on a form prepared and furnished by the department, which shall include a written statement or report prepared and signed by a licensed physician, a licensed physician assistant, a licensed chiropractor, a licensed podiatrist, or a certified licensed advanced practice registered nurse prescriber prepared no more than 6 months preceding the application and verifying that the applicant is physically disabled.

SB249,4 Section 4 . 29.193 (2) (c) 3. of the statutes is amended to read:

SB249,5,20 29.193 (2) (c) 3. The department may issue a Class B permit to an applicant who is ineligible for a permit under subd. 1., 2. or 2m. or who is denied a permit under subd. 1., 2. or 2m. if, upon review and after considering the physical condition of the applicant and the recommendation of a licensed physician, a licensed physician assistant, a licensed chiropractor, a licensed podiatrist, or a certified licensed advanced practice registered nurse prescriber selected by the applicant from a list of licensed physicians, licensed physician assistants, licensed chiropractors, licensed podiatrists, and certified licensed advanced practice nurse prescribers registered nurses compiled by the department, the department finds that issuance of a permit complies with the intent of this subsection. The use of this review procedure is discretionary with the department and all costs of the review procedure shall be paid by the applicant.

SB249,5 Section 5 . 29.193 (2) (cd) 2. b. of the statutes is amended to read:

SB249,6,2 29.193 (2) (cd) 2. b. The person has a permanent substantial loss of function in one or both arms and fails to meet the minimum standards of the standard upper extremity pinch test, the standard grip test, or the standard nine-hole peg test, administered under the direction of a licensed physician, a licensed physician assistant, a licensed chiropractor, or a certified licensed advanced practice registered nurse prescriber.

SB249,6 Section 6 . 29.193 (2) (cd) 2. c. of the statutes is amended to read:

SB249,6,8 29.193 (2) (cd) 2. c. The person has a permanent substantial loss of function in one or both shoulders and fails to meet the minimum standards of the standard shoulder strength test, administered under the direction of a licensed physician, a licensed physician assistant, a licensed chiropractor, or a certified licensed advanced practice registered nurse prescriber.

SB249,7 Section 7 . 29.193 (2) (e) of the statutes is amended to read:

SB249,6,19 29.193 (2) (e) Review of decisions. An applicant denied a permit under this subsection, except a permit under par. (c) 3., may obtain a review of that decision by a licensed physician, a licensed physician assistant, a licensed chiropractor, a licensed podiatrist, or a certified licensed advanced practice registered nurse prescriber designated by the department and with an office located in the department district in which the applicant resides. The department shall pay for the cost of a review under this paragraph unless the denied application on its face fails to meet the standards set forth in par. (c) 1. or 2. A review under this paragraph is the only method of review of a decision to deny a permit under this subsection and is not subject to further review under ch. 227.

SB249,8 Section 8 . 29.193 (3) (a) of the statutes is amended to read:

SB249,6,24 29.193 (3) (a) Produces a certificate from a licensed physician, a licensed physician assistant, a licensed optometrist, or a certified licensed advanced practice registered nurse prescriber stating that his or her sight is impaired to the degree that he or she cannot read ordinary newspaper print with or without corrective glasses.

SB249,9 Section 9 . 45.40 (1g) (a) of the statutes is amended to read:

SB249,7,5 45.40 (1g) (a) “Health care provider" means an advanced practice registered nurse prescriber certified who holds a permit to issue prescription orders under s. 441.16 441.09 (2), an audiologist licensed under ch. 459, a dentist licensed under ch. 447, an optometrist licensed under ch. 449, a physician licensed under s. 448.02, or a podiatrist licensed under s. 448.63.

SB249,10 Section 10 . 46.03 (44) of the statutes is amended to read:

SB249,7,15 46.03 (44) Sexually transmitted disease treatment information. Prepare and keep current an information sheet to be distributed to a patient by a physician, a physician assistant, or certified an advanced practice registered nurse prescriber who holds a permit to issue prescription orders under s. 441.09 (2) providing expedited partner therapy to that patient under s. 448.035. The information sheet shall include information about sexually transmitted diseases and their treatment and about the risk of drug allergies. The information sheet shall also include a statement advising a person with questions about the information to contact his or her physician, pharmacist, or local health department, as defined in s. 250.01 (4).

SB249,11 Section 11. 50.01 (1b) of the statutes is repealed.

SB249,12 Section 12 . 50.08 (2) of the statutes is amended to read:

SB249,7,23 50.08 (2) A physician, an advanced practice registered nurse prescriber certified who holds a permit to issue prescription orders under s. 441.16 441.09 (2), or a physician assistant licensed under ch. 448, who prescribes a psychotropic medication to a nursing home resident who has degenerative brain disorder shall notify the nursing home if the prescribed medication has a boxed warning under 21 CFR 201.57.

SB249,13 Section 13 . 50.09 (1) (a) (intro.) of the statutes is amended to read:

SB249,8,8 50.09 (1) (a) (intro.) Private and unrestricted communications with the resident's family, physician, physician assistant, advanced practice registered nurse prescriber, attorney, and any other person, unless medically contraindicated as documented by the resident's physician, physician assistant, or advanced practice registered nurse prescriber in the resident's medical record, except that communications with public officials or with the resident's attorney shall not be restricted in any event. The right to private and unrestricted communications shall include, but is not limited to, the right to:

SB249,14 Section 14 . 50.09 (1) (f) 1. of the statutes is amended to read:

SB249,8,14 50.09 (1) (f) 1. Privacy for visits by spouse or domestic partner. If both spouses or both domestic partners under ch. 770 are residents of the same facility, the spouses or domestic partners shall be permitted to share a room unless medically contraindicated as documented by the resident's physician, physician assistant, or advanced practice registered nurse prescriber in the resident's medical record.

SB249,15 Section 15 . 50.09 (1) (h) of the statutes is amended to read:

SB249,8,19 50.09 (1) (h) Meet with, and participate in activities of social, religious, and community groups at the resident's discretion, unless medically contraindicated as documented by the resident's physician, physician assistant, or advanced practice registered nurse prescriber in the resident's medical record.

SB249,16 Section 16 . 50.09 (1) (k) of the statutes is amended to read:

SB249,9,7 50.09 (1) (k) Be free from mental and physical abuse, and be free from chemical and physical restraints except as authorized in writing by a physician, physician assistant, or advanced practice registered nurse prescriber for a specified and limited period of time and documented in the resident's medical record. Physical restraints may be used in an emergency when necessary to protect the resident from injury to himself or herself or others or to property. However, authorization for continuing use of the physical restraints shall be secured from a physician, physician assistant, or advanced practice registered nurse prescriber within 12 hours. Any use of physical restraints shall be noted in the resident's medical records. “ Physical restraints" includes, but is not limited to, any article, device, or garment that interferes with the free movement of the resident and that the resident is unable to remove easily, and confinement in a locked room.

SB249,17 Section 17 . 50.49 (1) (b) (intro.) of the statutes is amended to read:

SB249,9,17 50.49 (1) (b) (intro.) “Home health services" means the following items and services that are furnished to an individual, who is under the care of a physician, physician assistant, or advanced practice registered nurse prescriber, by a home health agency, or by others under arrangements made by the home health agency, that are under a plan for furnishing those items and services to the individual that is established and periodically reviewed by a physician, physician assistant, or advanced practice registered nurse prescriber and that are, except as provided in subd. 6., provided on a visiting basis in a place of residence used as the individual's home:

SB249,18 Section 18 . 51.41 (1d) (b) 4. of the statutes is amended to read:

SB249,9,25 51.41 (1d) (b) 4. A psychiatric mental health advanced practice registered nurse who is suggested by the Milwaukee County board of supervisors. The Milwaukee County board of supervisors shall solicit suggestions from organizations including the Wisconsin Nurses Association for individuals who specialize in a full continuum of behavioral health and medical services including emergency detention, inpatient, residential, transitional, partial hospitalization, intensive outpatient, and wraparound community-based services. The Milwaukee County board of supervisors shall suggest to the Milwaukee County executive 4 psychiatric mental health advanced practice registered nurses for this board membership position.

SB249,19 Section 19 . 70.47 (8) (intro.) of the statutes is amended to read:

SB249,10,17 70.47 (8) Hearing. (intro.) The board shall hear upon oath all persons who appear before it in relation to the assessment. Instead of appearing in person at the hearing, the board may allow the property owner, or the property owner's representative, at the request of either person, to appear before the board, under oath, by telephone or to submit written statements, under oath, to the board. The board shall hear upon oath, by telephone, all ill or disabled persons who present to the board a letter from a physician, osteopath, physician assistant, as defined in s. 448.01 (6), or advanced practice registered nurse prescriber certified under s. 441.16 (2) licensed under ch. 441 that confirms their illness or disability. At the request of the property owner or the property owner's representative, the board may postpone and reschedule a hearing under this subsection, but may not postpone and reschedule a hearing more than once during the same session for the same property. The board at such hearing shall proceed as follows:

SB249,20 Section 20 . 77.54 (14) (f) 3. of the statutes is repealed.

SB249,21 Section 21 . 77.54 (14) (f) 4. of the statutes is amended to read:

SB249,10,21 77.54 (14) (f) 4. An advanced practice registered nurse who holds a permit to issue prescription orders under s. 441.09 (2).

SB249,22 Section 22 . 97.59 of the statutes is amended to read:

SB249,11,10 97.59 Handling foods. No person in charge of any public eating place or other establishment where food products to be consumed by others are handled may knowingly employ any person handling food products who has a disease in a form that is communicable by food handling. If required by the local health officer or any officer of the department for the purposes of an investigation, any person who is employed in the handling of foods or is suspected of having a disease in a form that is communicable by food handling shall submit to an examination by the officer or by a physician, physician assistant, or advanced practice registered nurse prescriber designated by the officer. The expense of the examination, if any, shall be paid by the person examined. Any person knowingly infected with a disease in a form that is communicable by food handling who handles food products to be consumed by others and any persons knowingly employing or permitting such a person to handle food products to be consumed by others shall be punished as provided by s. 97.72.

SB249,23 Section 23 . 102.13 (1) (a) of the statutes is amended to read:

SB249,11,23 102.13 (1) (a) Except as provided in sub. (4), whenever compensation is claimed by an employee, the employee shall, upon the written request of the employee's employer or worker's compensation insurer, submit to reasonable examinations by physicians, chiropractors, psychologists, dentists, physician assistants, advanced practice nurse prescribers registered nurses, or podiatrists provided and paid for by the employer or insurer. No employee who submits to an examination under this paragraph is a patient of the examining physician, chiropractor, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, or podiatrist for any purpose other than for the purpose of bringing an action under ch. 655, unless the employee specifically requests treatment from that physician, chiropractor, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, or podiatrist.

SB249,24 Section 24 . 102.13 (1) (b) (intro.), 1., 3. and 4. of the statutes are amended to read:

SB249,12,14 102.13 (1) (b) (intro.) An employer or insurer who requests that an employee submit to reasonable examination under par. (a) or (am) shall tender to the employee, before the examination, all necessary expenses including transportation expenses. The employee is entitled to have a physician, chiropractor, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, or podiatrist provided by himself or herself present at the examination and to receive a copy of all reports of the examination that are prepared by the examining physician, chiropractor, psychologist, podiatrist, dentist, physician assistant, advanced practice registered nurse prescriber, or vocational expert immediately upon receipt of those reports by the employer or worker's compensation insurer. The employee is also entitled to have a translator provided by himself or herself present at the examination if the employee has difficulty speaking or understanding the English language. The employer's or insurer's written request for examination shall notify the employee of all of the following:

SB249,12,18 1. The proposed date, time, and place of the examination and the identity and area of specialization of the examining physician, chiropractor, psychologist, dentist, podiatrist, physician assistant, advanced practice registered nurse prescriber, or vocational expert.

SB249,12,21 3. The employee's right to have his or her physician, chiropractor, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, or podiatrist present at the examination.

SB249,13,2 4. The employee's right to receive a copy of all reports of the examination that are prepared by the examining physician, chiropractor, psychologist, dentist, podiatrist, physician assistant, advanced practice registered nurse prescriber, or vocational expert immediately upon receipt of these reports by the employer or worker's compensation insurer.

SB249,25 Section 25 . 102.13 (1) (d) 1., 2., 3. and 4. of the statutes are amended to read:

SB249,13,7 102.13 (1) (d) 1. Any physician, chiropractor, psychologist, dentist, podiatrist, physician assistant, advanced practice registered nurse prescriber, or vocational expert who is present at any examination under par. (a) or (am) may be required to testify as to the results of the examination.

SB249,13,12 2. Any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, or podiatrist who attended a worker's compensation claimant for any condition or complaint reasonably related to the condition for which the claimant claims compensation may be required to testify before the division when the division so directs.

SB249,13,19 3. Notwithstanding any statutory provisions except par. (e), any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, or podiatrist attending a worker's compensation claimant for any condition or complaint reasonably related to the condition for which the claimant claims compensation may furnish to the employee, employer, worker's compensation insurer, department, or division information and reports relative to a compensation claim.

SB249,13,24 4. The testimony of any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, or podiatrist who is licensed to practice where he or she resides or practices in any state and the testimony of any vocational expert may be received in evidence in compensation proceedings.

SB249,26 Section 26. 102.13 (2) (a) of the statutes is amended to read:

SB249,14,11 102.13 (2) (a) An employee who reports an injury alleged to be work-related or files an application for hearing waives any physician-patient, psychologist-patient, or chiropractor-patient privilege with respect to any condition or complaint reasonably related to the condition for which the employee claims compensation. Notwithstanding ss. 51.30 and 146.82 and any other law, any physician, chiropractor, psychologist, dentist, podiatrist, physician assistant, advanced practice registered nurse prescriber, hospital, or health care provider shall, within a reasonable time after written request by the employee, employer, worker's compensation insurer, department, or division, or its representative, provide that person with any information or written material reasonably related to any injury for which the employee claims compensation.

SB249,27 Section 27 . 102.13 (2) (b) of the statutes is amended to read:

SB249,14,23 102.13 (2) (b) A physician, chiropractor, podiatrist, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, hospital, or health service provider shall furnish a legible, certified duplicate of the written material requested under par. (a) in paper format upon payment of the actual costs of preparing the certified duplicate, not to exceed the greater of 45 cents per page or $7.50 per request, plus the actual costs of postage, or shall furnish a legible, certified duplicate of that material in electronic format upon payment of $26 per request. Any person who refuses to provide certified duplicates of written material in the person's custody that is requested under par. (a) shall be liable for reasonable and necessary costs and, notwithstanding s. 814.04 (1), reasonable attorney fees incurred in enforcing the requester's right to the duplicates under par. (a).

SB249,28 Section 28 . 102.17 (1) (d) 1. and 2. of the statutes are amended to read:

SB249,15,21 102.17 (1) (d) 1. The contents of certified medical and surgical reports by physicians, podiatrists, surgeons, dentists, psychologists, physician assistants, advanced practice nurse prescribers registered nurses, and chiropractors licensed in and practicing in this state, and of certified reports by experts concerning loss of earning capacity under s. 102.44 (2) and (3), presented by a party for compensation constitute prima facie evidence as to the matter contained in those reports, subject to any rules and limitations the division prescribes. Certified reports of physicians, podiatrists, surgeons, dentists, psychologists, physician assistants, advanced practice nurse prescribers registered nurses, and chiropractors, wherever licensed and practicing, who have examined or treated the claimant, and of experts, if the practitioner or expert consents to being subjected to cross-examination, also constitute prima facie evidence as to the matter contained in those reports. Certified reports of physicians, podiatrists, surgeons, psychologists, and chiropractors are admissible as evidence of the diagnosis, necessity of the treatment, and cause and extent of the disability. Certified reports by doctors of dentistry, physician assistants, and advanced practice nurse prescribers registered nurses are admissible as evidence of the diagnosis and necessity of treatment but not of the cause and extent of disability. Any physician, podiatrist, surgeon, dentist, psychologist, chiropractor, physician assistant, advanced practice registered nurse prescriber, or expert who knowingly makes a false statement of fact or opinion in a certified report may be fined or imprisoned, or both, under s. 943.395.

SB249,16,4 2. The record of a hospital or sanatorium in this state that is satisfactory to the division, established by certificate, affidavit, or testimony of the supervising officer of the hospital or sanatorium, any other person having charge of the record, or a physician, podiatrist, surgeon, dentist, psychologist, physician assistant, advanced practice registered nurse prescriber, or chiropractor to be the record of the patient in question, and made in the regular course of examination or treatment of the patient, constitutes prima facie evidence as to the matter contained in the record, to the extent that the record is otherwise competent and relevant.

SB249,29 Section 29 . 102.29 (3) of the statutes is amended to read:

SB249,16,10 102.29 (3) Nothing in this chapter shall prevent an employee from taking the compensation that the employee may be entitled to under this chapter and also maintaining a civil action against any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, or podiatrist for malpractice.

SB249,30 Section 30 . 102.42 (2) (a) of the statutes is amended to read:

SB249,16,24 102.42 (2) (a) When the employer has notice of an injury and its relationship to the employment, the employer shall offer to the injured employee his or her choice of any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice registered nurse prescriber, or podiatrist licensed to practice and practicing in this state for treatment of the injury. By mutual agreement, the employee may have the choice of any qualified practitioner not licensed in this state. In case of emergency, the employer may arrange for treatment without tendering a choice. After the emergency has passed the employee shall be given his or her choice of attending practitioner at the earliest opportunity. The employee has the right to a 2nd choice of attending practitioner on notice to the employer or its insurance carrier. Any further choice shall be by mutual agreement. Partners and clinics are considered to be one practitioner. Treatment by a practitioner on referral from another practitioner is considered to be treatment by one practitioner.

SB249,31 Section 31. 106.30 (1) of the statutes is amended to read:

SB249,17,5 106.30 (1) Definition. In this section, “nurse" means a registered nurse licensed under s. 441.06 or permitted under s. 441.08, a licensed practical nurse licensed or permitted under s. 441.10, or an advanced practice registered nurse prescriber certified under s. 441.16 (2), or a nurse-midwife licensed under s. 441.15 441.09.

SB249,32 Section 32 . 118.15 (3) (a) of the statutes is amended to read:

SB249,17,17 118.15 (3) (a) Any child who is excused by the school board because the child is temporarily not in proper physical or mental condition to attend a school program but who can be expected to return to a school program upon termination or abatement of the illness or condition. The school attendance officer may request the parent or guardian of the child to obtain a written statement from a licensed physician, dentist, chiropractor, optometrist, psychologist, physician assistant, or nurse practitioner, as defined in s. 255.06 (1) (d), or certified advanced practice registered nurse prescriber or Christian Science practitioner living and residing in this state, who is listed in the Christian Science Journal, as sufficient proof of the physical or mental condition of the child. An excuse under this paragraph shall be in writing and shall state the time period for which it is valid, not to exceed 30 days.

SB249,33 Section 33 . 118.25 (1) (a) of the statutes is amended to read:

SB249,17,22 118.25 (1) (a) “Practitioner" means a person licensed as a physician or as a physician assistant in any state or licensed as an advanced practice registered nurse or certified as an advanced practice registered nurse prescriber in any state. In this paragraph, “physician” has the meaning given in s. 448.01 (5).

SB249,34 Section 34 . 118.29 (1) (e) of the statutes is amended to read:

SB249,18,3 118.29 (1) (e) “Practitioner" means any physician, dentist, optometrist, physician assistant, advanced practice registered nurse prescriber with prescribing authority, or podiatrist licensed in any state.