Form 4NP - Verification of Collaborative Agreement and 2025

1. Click ‘Get Form’ to open it in the editor.
2. In Section I, provide your personal information. Enter your Social Security Number and Birth Date. If you are already certified, include your New York State Nurse Practitioner Certificate Number. Ensure that your name matches exactly as it appears on your Application for Certificate (Form 1). Fill in your mailing address accurately.
3. Move to Section II, where you will need to enter details about your collaborating physician. Include their name, address, telephone number, email address, New York State medical license number, area of current practice, and area of specialty practice.
4. In Section III, select an approved practice protocol text from the list provided by the Office of the Professions. Document the title, publisher, and publication date. Describe your practice site(s) and provide a brief description of your practice including any mutually agreed-upon exceptions.
5. Finally, 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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