N.H. Admin. Code § Ch 302.04

Current through Register No. 50, December 12, 2024

Section Ch 302.04 - Information Required by the Application Form

An applicant for initial licensure shall supply the following information on the "Application for a License to Practice Chiropractic" form, effective October 2017:

(a) The applicant's full name, physical address, mailing address, telephone number and e-mail address, if any;

(b) The applicant's social security number pursuant to RSA 161-B:11, VI-a, date of birth, height, weight, eye color and hair color;

(c) The applicant's national provider identifier, if known;

(d) The applicant's physical address for the past 5 years;

(e) Whether the applicant has any physical, mental, or other condition or disability affecting the applicant's ability to practice chiropractic;

(f) Whether the applicant has any physical, mental or other condition or disability for which continuing remedial or therapeutic action is required to ensure the applicant's continuing ability to practice chiropractic;

(g) Whether the applicant uses alcohol or controlled or non-controlled drugs in a manner affecting the applicant's ability to practice chiropractic;

(h) Whether the applicant has ever been convicted of a felony or misdemeanor;

(i) If any answer to (e), (f), (g), or (h) is affirmative, a summary statement explaining the answer and specifying as applicable:

(1) The physical, mental or other condition or disability;

(2) The remedial or therapeutic action;

(3) The use of alcohol or controlled or non-controlled drugs; and

(4) The charges of which the applicant was convicted, the conviction date, and the sentence imposed or other disposition;

(j) For each post- secondary educational institution attended by the applicant, regardless of degrees earned, the following information:

(1) The name of the institution;

(2) The address of the institution;

(3) The dates of the applicant's attendance; and

(4) The degree awarded by the institution, if any;

(k) For any chiropractic college attended, its name, address, the dates attended by the applicant, and the date of the applicant's graduation;

(l) Whether the applicant currently holds, or has previously held, any professional license, certification or registration to practice any method of healing other than chiropractic;

(m) If the answer to (l) is affirmative, the type of license(s) held and the issuing jurisdiction or state;

(n) Whether the applicant currently holds, or has previously held, any license to practice chiropractic;

(o) For every license to practice chiropractic held in the past or at present:

(1) The issuing jurisdiction or state;

(2) The license date;

(3) The license number; and

(4) If applicable, the reason the applicant no longer holds the license;

(p) Whether the applicant has ever been refused:

(1) A license to practice chiropractic; or

(2) Any other professional license, certification or registration;

(q) For every refusal of a license, certification or registration as described in paragraph (p) above:

(1) The name and address of the licensing, certifying or registering body;

(2) The date of refusal; and

(3) The reason for the refusal;

(r) Whether the applicant has ever had any disciplinary action taken by any other jurisdiction against the applicant's chiropractic license or any other professional license, certification or registration;

(s) Whether, during the past 10 years there have been, or whether there are now, complaints pending, or investigations being conducted, in connection with any professional license, certification or registration previously or currently held by the applicant;

(t) Whether, to the best of the applicant's knowledge, there are currently pending any malpractice claims, settlements or judgments;

(u) Whether, in the past 10 years, any malpractice claims have been settled or resolved, or malpractice judgments issued, against the applicant; and

(v) If any answer to (r), (s), (t), or (u) is affirmative, a detailed written explanation of the circumstances.

N.H. Admin. Code § Ch 302.04

#5624, eff 5-18-93; ss by #6288, eff 7-19-96; EXPIRED: 7-19-04

New. #8187, eff 10-8-04; ss by #9357, eff 1-10-09

Amended by Volume XXXVII Number 10, Filed March 9, 2017, Proposed by #12107, Effective 2/21/2017, Expires8/20/2017.

Amended by Volume XXXVII Number 50, Filed December 14, 2017, Proposed by #12431, Effective 12/8/2017, Expires 12/8/2027.