Emedny 410501 Form PDF Details

Emedny 410501 is a NYS DOB form that is used to certify the accuracy of work done by contractors. The form must be completed and submitted by the contractor before payment can be made for the work performed. The purpose of this blog post is to provide an overview of Emedny 410501, including what information is required on the form and how it should be filled out. Additionally, we will discuss some common mistakes that contractors make when completing this form. We hope that this information will help you to understand and properly complete Emedny 410501. Thank you for choosing our company as your source of construction-related information.

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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