The University of the State of New York
The State Education Department
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Nurse Practitioner Form NP-CR
Collaborative Relationships Attestation Form
Instructions
This form must be filled out and signed by nurse practitioners (with more than 3,600 hours of qualifying nurse practitioner practice experience)
who choose to practice and have collaborative relationships - instead of practicing in accordance with a written practice agreement with a
collaborating physician. Once completed, a nurse practitioner must keep this form at the nurse practitioner's practice location and provide it to
the New York State Education Department upon request. The nurse practitioner must ensure that information on this form is current, and
should complete a new Form NP-CR, as appropriate, to update information. Nurse practitioners who practice in accordance with a written
practice agreement with a collaborating physician do not have to fill out a Form NP-CR
To be completed by Certified Nurse Practitioners who have Collaborative Relationships Pursuant to Education Law §6902(3)(b)
1. Provide your name exactly as it appears on your current New York State Education Department issued nurse practitioner registration
certificate(s)
2. Provide your nurse practitioner registration number(s)
3. Identity the nurse specialty area(s) of nurse practitioner practice in which you are certified by the New York State Education Department
Acute Care Adult Health College Health Community Health Family Health
Gerontology Holistic Care Neonatology Obstetrics/Gynecology Oncology
Pediatrics Palliative Care Perinatology Psychiatry School Health
Womens Health
Nurse Practitioner Form NP-CR, Page 1 of 2, Revised 5/17
4. By placing your initials below, you attest that you are certified as a Nurse Practitioner in New York State and have more than 3,600 hours
of experience practicing as a licensed or certified nurse practitioner pursuant to the laws of New York State or another State or working as
a nurse practitioner for the United States veteran's administration, the United States armed forces or the United States public health
service.
Place Initials here
5. By placing your initials below, you attest that you have collaborative relationships with one or more New York State licensed physicians
qualified to collaborate in the specialty involved or with a New York State Department of Health licensed hospital that provides services
through licensed physicians qualified to collaborate in the specialty involved and having privileges at such institution. A collaborative
relationship means that you communicate, as required by New York State Education Department regulation, with the qualified physician
for the purposes of exchanging information, as needed, in order to provide comprehensive patient care and to make referrals as
necessary.
Place Initials here
6. By placing your initials below, you attest that you maintain current and accurate documentation supportive of your collaborative
relationships and, upon request by New York State Education Department, you will produce evidence of the collaborative relationships,
such as: (a) an agreement or an arrangement with a hospital or a physician practice pursuant to which you may transfer or refer patients
for care; (b) written communications or records of consultations and communications for referral; (c) documentation of employment
relationships with a physician practice or a hospital, hospice program, licensed home care services agency or licensed mental health care
facility with a physician medical director; or (d) documentation of contractual relationship with a physician, physician practice, or a
hospital, pursuant to which you provide professional services, or (e) (other please describe):
Place Initials here
