Get Ny Form 4np 2017-2025

This guide provides clear and detailed instructions on how to complete the New York Form 4NP online. By following the steps outlined below, you will ensure that your form is filled out correctly and submitted timely.

Follow the steps to complete your NY Form 4NP online.

1. Click 'Get Form' button to retrieve the NY Form 4NP and open it for editing.
2. In Section I, complete your applicant information. Enter your Social Security number and birth date. If you do not have a U.S. Social Security number, leave that field blank. If you are already certified, provide your New York State Nurse Practitioner Certificate number. Ensure that you print your name exactly as it appears on your application for a certificate (Form 1), and fill in your mailing address completely.
3. Proceed to Section II, which requires you to provide details about your collaborating physician. Fill in 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, you must select an approved practice protocol text from the appropriate list. Fill in the title, publisher, and publication date of this protocol text. Then, describe the location and details of your practice site(s). List the name, address, and provide a brief description of the practice.
5. Next, describe the overall practice, including any agreed-upon exceptions within your collaborative agreement. Ensure that both you and your collaborating physician sign and date the form in Section III.
6. After completing all sections, review the form for accuracy. Once satisfied, you can save your changes, download the form, or print it directly. Make sure to return the completed form to the specified address within 90 days of commencing practice.

Complete your NY Form 4NP online today to ensure a smooth certification process.