Section Med 604.01 - Application Form(a) Applicants for licensure as a physician assistant shall complete and submit form "Application for Certification as a Physician Assistant," revised 6/2021, containing the following: (1) Name, home address, email address, and telephone number of the applicant;(2) Date of birth, place of birth, gender of the applicant and social security number required pursuant to 45CFR Part 60.8 and RSA 161-B:11, VI-a. The applicant shall furnish his or her social security number on the line provided below the following preprinted statement: "The board will deny licensure if you refuse to submit your social security number (SSN). Your professional license will not display your SSN. Your SSN will not be made available to the public. The board is required to obtain your SSN for the purpose of child support enforcement and in compliance with RSA 161-B:11. This collection of your SSN is mandatory.";
(3) Documentation of completion of an approved program of education as defined in Med 601.02;(4) Verification from the licensing authority of any other state license ever held by the applicant which shows such license to be in good standingthrough the use of the "Licensure Verification Form" dated 6/2021;(5) Documentation that the applicant has passed an initial examination administered by the NCCPA and continues to hold a valid national certificate issued by that organization or its successor agency;(6) A statement indicating whether the applicant has ever been refused a license or certification by any other licensing or certifying body and if so, the circumstances of the incident;(7) A statement indicating whether the applicant has ever been or has reason to believe that he or she is the subject of any kind of disciplinary investigation or action by any hospital, healthcare organization, or licensing or certifying body and if so, the nature of the allegations and the subsequent disposition of the action;(8) A statement indicating whether the applicant has ever been convicted of a felony or misdemeanor, and, if so, the name of the court, the details of the offense, the date of conviction and the sentence imposed;(9) A statement indicating whether the applicant is currently or has in the past been monitored or treated by a private, state, medical society, or hospital physician health program other than the NH board-approved physician health program;(10) A statement indicating whether the applicant is currently suffering from any condition, mental or physical, that impairs their judgment or that would otherwise adversely affect his or her ability to practice medicine in a competent, ethical, and professional manner;(11) A statement that the applicant has arranged for the direct submission of letters of reference from 2 physicians, who have served in an advisory capacity to the applicant;(12) Signature and 3 x 5 inch full face photograph of the applicant; and(13) A signed, affidavit stating the following: "[NAME] of [ADDRESS], being duly sworn, says that (s)he is the person referred to in the above application for certification (and photograph below) as a Physician Assistant in the state of New Hampshire; that (s)he is a graduate of an approved program for Physician Assistants; and that all statements herein or attached hereto are each and all true in every respect."
(b) A copy of the applicant's curriculum vitae or resume shall accompany the application.(c) Letters of reference required in (a)(11) above shall be original, signed documents submitted directly to the board on professional letterhead.(d) Applicants shall include the application fee required in Table 3.6.1 in Med 306.01.N.H. Admin. Code § Med 604.01
#1497, eff 11-29-79, ss by #2199, eff 12-2-82; ss by #2197, eff 12-2-82; ss by #2910, eff 11-21-84; ss by #4745, eff 1-25-90, EXPIRED 1-25-96
New. #6472, eff 3-25-97, EXPIRED: 3-25-05
New. #8678, eff 7-11-06; ss by #9900, eff 4-12-11 (see Revision Note at chapter heading for Med 600)
Amended by Volume XL Number 7, Filed February 13, 2020, Proposed by #12972, Effective 1/10/2020, Expires 1/10/2030Amended by Volume XLI Number 36, Filed September 9, 2021, Proposed by #13249, Effective 8/6/2021, Expires 8/6/2031.