Form 4NP - Verification of Collaborative Agreement and 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, provide your personal information. Enter your Social Security Number, Birth Date, and if applicable, your New York State Nurse Practitioner Certificate Number. Ensure that you print your name exactly as it appears on your Application for Certificate (Form 1).
3. Complete the mailing address section accurately. Remember to notify the Department of any changes in your address or name.
4. Move to Section II and fill in the details of your collaborating physician, including their name, address, telephone number, email address, medical license number, area of current practice, and specialty practice.
5. In Section III, select an approved practice protocol text from the provided list. Fill in the title, publisher, and publication date of this text. Describe your practice site(s) and provide a detailed description of your practice.
6. Both you and the collaborating physician must sign and date the form in Section III to verify that a written collaborative agreement exists.

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