How to Fill Out and File New York Form 4NP: Sections and Protocols

New York Form 4NP is the two-page verification a nurse practitioner files with the State Education Department’s Office of the Professions to confirm that a written collaborative practice agreement and written practice protocols are in place with a licensed physician. You complete Section I, your collaborating physician completes Section II, you both complete and sign Section III, and you mail the form to the Nurse Practitioner Unit in Albany within 90 days of starting practice. It only gets filed once.¹

Do You Need to File Form 4NP

New York Education Law Section 6902 requires every nurse practitioner with 3,600 or fewer hours of qualifying practice to work under a written practice agreement and written protocols with a collaborating physician. Qualifying hours include time practicing as a licensed or certified nurse practitioner under New York law or another state’s law, or while employed by the U.S. Veterans Administration, the U.S. Armed Forces, or the U.S. Public Health Service.²

Once you cross 3,600 hours, the collaboration requirement ends and you may practice independently.³ A newly certified nurse practitioner who already has more than 3,600 qualifying hours from out-of-state practice may still choose to enter a collaborative relationship but is not required to file Form 4NP.

What Has to Exist Before You Fill Out the Form

Form 4NP is a verification, not the agreement itself. Two documents must already be in place before you start filling it out: a written collaborative practice agreement with a qualified physician and a set of written practice protocols based on an approved protocol text from the Office of the Professions’ published list. Choosing a protocol text that is not on the approved list will create problems with your submission.¹

Have the following ready before you sit down with the form:

Your full legal name exactly as it appears on your Application for Certificate (Form 1).
Your mailing address and contact information.
Your collaborating physician’s full name, address, telephone, fax, and email.
The physician’s New York State medical license number.
The physician’s area of current practice and specialty.
The title, publisher, and publication date of your approved practice protocol text.
The name, address, and description of every practice site where you will work (clinic, private office, HMO, and so on).

How to Complete the Form Section by Section

Form 4NP is two pages with three sections. Download it from the NYSED Office of the Professions website.¹

Section I: Applicant Information

You complete this section alone. Enter your name in Item 4 exactly as it appears on your Form 1 application. A mismatch between the two forms can delay processing. Provide your full mailing address. You are also required to notify the Department promptly of any future address or name change.

Section II: Collaborating Physician

Your collaborating physician fills in their name, address, telephone, fax, and email. The physician’s New York State medical license number goes in Item 5. Items 6 and 7 ask for the area of current practice and the specialty area. The physician must be qualified to collaborate in your specific specialty; a cardiologist cannot serve as the collaborating physician for a psychiatric nurse practitioner.³ Confirm the physician’s license is active and in good standing before entering the number.

Section III: Practice Protocol

Both parties complete this section. Item 1 asks for the title, publisher, and publication date of the approved protocol text you selected from the NYSED list. Item 2 asks for the name, address, and description of each practice site; list all of them if you work in multiple locations. Item 3 asks for a description of the practice, including any exceptions the nurse practitioner and physician have mutually agreed upon.¹

Item 4 is the attestation. Both the nurse practitioner and the collaborating physician sign and date, verifying that a written collaborative agreement is in place and that practice protocols have been selected. Both signatures are required. An incomplete signature block will hold up the submission.

Where and When to Mail It

Send both pages of the completed form to:

New York State Education Department
Office of the Professions
Division of Professional Licensing Services
Nurse Practitioner Unit
89 Washington Avenue
Albany, NY 12234-1000¹

The form is not required to obtain your nurse practitioner certificate, but it must reach the Office of the Professions no later than 90 days after you begin practicing. You file it once. There is no annual renewal for Form 4NP itself, and the form instructions do not list a separate fee for the submission.¹

What the Underlying Collaborative Agreement Must Contain

Form 4NP attests to a working contract between you and your physician, and state regulation spells out what that contract must address. The Department can review the agreement at any time.⁴ At a minimum, the agreement must cover:

Patient referral and consultation: how and when you refer patients to the collaborating physician or other specialists.
Emergency absence coverage: what happens when either you or the physician is unexpectedly unavailable.
Disagreement resolution: how disputes over diagnosis or treatment are handled. If the agreement is silent, the collaborating physician’s judgment prevails by statute.³
Patient record review: the collaborating physician must review your patient records in a timely fashion, and no less often than every three months. The law does not fix a specific number of charts; that judgment is left to the nurse practitioner and physician based on experience, patient population, and practice setting.²

You and the physician may add provisions that fit your arrangement, such as supervision frequency, communication methods for complex cases, or clinical situations that trigger immediate consultation.⁴

What the Practice Protocols Must Contain

The protocols are the clinical guidelines behind your day-to-day work. Under 8 NYCRR 64.5, they must identify the area of practice, reflect accepted standards of nursing and medical practice, and include provisions for case management covering diagnosis, treatment, and recordkeeping. Protocols may be updated periodically to reflect current clinical standards.⁴

The Department may review your protocols at any time. If it finds a protocol inadequate, it will notify both you and your collaborating physician in writing with the reasons, and you have 30 days to submit a revised protocol. Continuing to practice under a protocol the Department has found deficient constitutes unprofessional conduct for both the nurse practitioner and the physician.⁴

Keep the Agreement and Protocols on Site

Form 4NP goes to Albany, but the underlying collaborative agreement and protocols stay at your practice setting and must be available for Department inspection.⁴ Keep copies at each location if you practice at more than one. Inspections are not announced in advance, so the documents should be accessible at all times. A physical copy in a secure file or a readily retrievable digital copy both work, as long as you can produce them on request.²

1
New York State Education Department. Nurse Practitioner Form 4NP Verification of Collaborative Agreement and Practice Protocol
2
New York State Education Department Office of the Professions. Practice Requirements for Nurse Practitioners
3
New York State Senate. New York Education Code 6902 – Definition of Practice of Nursing
4
Cornell Law Institute. New York Code 8 NYCRR 64.5 – Nurse Practitioner Practice