Emedny 410501 Form PDF Details

When exploring the landscape of healthcare regulation in New York, the EmedNY 410501 form emerges as a crucial document, designed to streamline the collaboration between nurse practitioners and physicians. This form, serving as a testament to a collaborative agreement, is an essential tool in ensuring compliance with the Education Law Section 6902(3)(b). Specifically, the form is not mandated for nurse practitioners who have accumulated more than 3,600 hours of qualifying experience, highlighting a threshold of professional independence acquired through extensive practice. Required to be submitted alongside the Practitioner Enrollment NOTICE OF Form EMEDNY-436801, the EmedNY 410501 form details the names and National Provider Identifier (NPI) numbers of both the nurse practitioner and the collaborating physician, who must be enrolled in NY Medicaid. Additionally, it mandates the indication of the effective date of the collaboration. By requiring original signatures from both parties, the form underscores the personal and professional commitment to adhere to established protocols and regulatory standards. Positioned at the intersection of legal requirement and healthcare provision, the EmedNY 410501 form embodies New York State's initiative to uphold both the quality and the legality of collaborative healthcare practice.

QuestionAnswer
Form NameEmedny 410501 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names410501 pdf, emedny, emedny410501, physician form collaborative

Form Preview Example

 

Unless submitting with Practitioner Enrollment

NOTICE OF

Form EMEDNY-436801,

Mail to:

COLLABORATING AGREEMENT

eMedNY

Nurse Practitioner and Physician

PO Box 4610

 

Rensselaer, NY 12144-4610

 

 

Pursuant to Education Law Section 6902(3)(b), this form is not

required if the Nurse Practitioner has more than 3,600 hours of

qualifying nurse practitioner practice experience.

 

 

Name of Nurse Practitioner:

NPI of Nurse Practitioner:

 

 

Name of Collaborating Physician (who must be enrolled in NY Medicaid):

NPI of Physician:

 

 

Effective Date of Collaborating Agreement:

 

CERTIFICATION

In accordance with the requirements of the laws and regulations of the New York State Education Department, the two individuals signing below confirm they have established a written collaborative agreement and practice protocols.

__________________________________________________

__________________________________

Signature of Nurse Practitioner (original; no stamps)

Date

__________________________________________________

__________________________________

Signature of Collaborating Physician (original; no stamps)

Date

EMEDNY-410501 (10/16)1

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