Form 4NP - Verification of Collaborative Agreement and Practice Protocol

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Note: Nurse practitioners (NPs) with more than 3,600 hours of experience as an NP licensed in any state or working for US Armed Forces, US Veterans Administration or the Public Health Service can choose to practice and have collaborative relationships instead of practicing in pursuant to a written practice agreement with a collaborating physician. Newly certified NPs (with more than 3,600 hours of qualifying NP experience) who choose to practice and have collaborative relationships as allowed by New York Law SHOULD NOT fill out Form 4NP.

All other newly certified NPs must fill out and submit Form 4NP to the Office of the Professions NO LATER than 90 days after the commencement of practice. This submission to the Office of the Professions is only required once.

• Section I: Complete this section of the form.
• Sections II & III: You and the initial collaborating physician with whom you have a practice agreement and practice protocol must complete these sections and return both pages of the form to the Office of the Professions at the address at the end of the form. Be sure to sign item 4 in Section III.