Get 4np Form

Filling out the 4np Form online is a straightforward process that ensures you provide all the necessary information to comply with New York State regulations for nurse practitioners. This guide will walk you through each section and field of the form to ensure a smooth submission.

Follow the steps to complete the 4np Form online effectively.

1. Click ‘Get Form’ button to retrieve the 4np Form and open it in your preferred digital editor.
2. Complete Section I by entering your applicant information. In item 4, enter your name exactly as it appears on your Application for a Certificate (Form 1). Additionally, provide your Social Security Number and Birth Date. If applicable, enter your New York State Nurse Practitioner Certificate Number. Ensure that you fill out your mailing address correctly.
3. In Section II, provide details about your collaborating physician. Enter their full name, address, telephone number, fax number, email address, New York State medical license number, area of current practice, and area of specialty practice.
4. Proceed to Section III and list the title, publisher, and date of publication of the approved practice protocol text. Use the approved list available on the Office of the Professions’ website.
5. Describe the location and details of your practice site(s), including the name, address, and a brief description of the practice setting.
6. In the final section, both the Nurse Practitioner and the collaborating physician must sign and date the form in the designated areas.
7. Once you have completed and reviewed the form, save your changes. You may also download, print, or share the form as needed before submission.

Start filling out your 4np Form online today to ensure timely compliance with New York State requirements.