Section Acp 401.03 - Application Form The "Acupuncture Renewal Application Form" shall require the applicant to supply the following information:
(b) Residence and business addresses and telephone numbers;(c) A statement indicating whether the applicant is actively practicing acupuncture;(d) Disclosure, and explanation where applicable, of the following information regarding the previous 2-year period: (1) If any malpractice claim has been made against the applicant, regardless of whether a lawsuit was filed in relation to the claim;(2) If the applicant has been denied an acupuncture license, certificate, or registration anywhere for any reason;(3) If the applicant had employment or appointment in a hospital, clinic or other health care facility suspended, or resigned from a health care facility in lieu of being subject to a disciplinary action;(4) If the applicant has any formal disciplinary charges pending or if any disciplinary action has been taken against the applicant by any acupuncture or medical board, any health care facility, or any professional acupuncture association;(5) If the applicant voluntarily surrendered a license to practice acupuncture or other healing art in lieu of facing disciplinary action;(6) If the applicant has convicted of a crime involving violence, abuse, fraud, dishonesty, or drugs;(7) If the applicant had a professional license in a field other than acupuncture revoked, suspended, or otherwise terminated on disciplinary grounds, or if any disciplinary actions are currently pending against the applicant in relation to any professional license held; and(8) If the applicant has had an emotional disturbance, mental illness, organic illness, or addictive disorder which impaired the applicant's ability to practice acupuncture, and if so, a description of the treatment received and the outcome of such treatment;(e) Answer yes or no to the question "Have you completed 30 hours of continuing education as described in Acp 402.01 ?";(f) An affirmation that the applicant is currently National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) certified, specifying the date of expiration;(g) The applicants signature and date of signing below the following statement: "I certify that the information I have provided on all parts of this renewal application form and in any documentation submitted to support my renewal application is, to the best of my knowledge, true, accurate, complete, and unaltered. I acknowledge that any misrepresentations and omissions of material facts may be cause for denial of license renewal and shall be a basis for disciplinary action by the board."
N.H. Admin. Code § Acp 401.03
#7081, eff 8-26-99; ss by #7872, eff 4-14-03; ss by #10004, INTERIM, eff 9-22-11, EXPIRES: 3-20-12
New. #10158, eff 6/27/2012.Amended by Number 15, Filed April 13, 2023, Proposed by #13578, Effective 5/8/2023, Expires 5/8/2033.