Section Med 608.01 - Renewal Application(a) On or before October 31, of every other year, the board shall forward a license renewal application for the coming year to each licensee. The applicant shall file the completed renewal application no later than December 31. For the transition from annual to biennial renewal, licensees who were initially licensed in odd-numbered years prior to 2021 shall renew by December 31, 2021 and every 2 years thereafter, and licensees who were initially licensed in even-numbered years shall renew by December 31, 2022 and every 2 years thereafter.(b) Persons seeking renewal of a physician assistant license shall complete and submit form "Physician Assistant Renewal Application," revised 6/2022, containing, on or as an attachment to the application, the following: (1) Name, telephone number, email address, and home address of the licensee, including street address and mailing address;(2) Place(s) of employment, business address, and business telephone number and business email address;(3) Name and New Hampshire license number of RSP;(4) Other states where the licensee holds a current license;(5) Copy of current national certification issued by the NCCPA;(6) The applicant's US Drug Enforcement Agency (DEA) license number, the state of issuance, and the expiration date;(7) Whether the applicant has, within the past 24 months, been found guilty or pleaded no contest to any felony or misdemeanor;(8) Whether the applicant has terminated a relationship with a registered supervisory physician or terminated employment for any reason during the past 24 months;(9) Whether the applicant has been the subject of disciplinary action, or has been denied a license or surrendered a license in any state or jurisdiction within the past 24 months;(10) Whether the applicant is currently or has in the past 24 months been monitored or treated by a private, state, medical society, or hospital physician health program other than through the NH board approved physician health program or has been restricted in any manner by the US Drug Enforcement Agency (DEA);(11) Whether the applicant is 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;(12) Whether the applicant has been the subject of any investigation or disciplinary proceeding or has been reported to the National Practitioners Data Bank (NPDB) within the past 24 months;(13) Whether any malpractice claims have been made against the applicant within the past 24 months;(14) If responses to questions (6) through (11) above are in the affirmative, a written explanation of the circumstances;(15) Whether the applicant has registered with the Controlled Drug Health and Safety Program also known as the N.H. Prescription Drug Monitoring Program;(16) The last 4 digits of 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.";(17) The applicant's signature and the date of the applicant's signature, certifying the accuracy of his or her responses under the penalty for unsworn falsification pursuant to RSA 641:3; and(18) The fee required in Med 306.01.(c) Applications which do not contain all of the information required in section (b) above shall not be accepted for filing and shall be returned, unprocessed to the applicant.(d) Pursuant to RSA 126-A:5, XVIII-a(a) and RSA 330-A:10-a, licensees shall complete, as part of their renewal application, the New Hampshire division of public health service's health professions survey issued by the state office of rural health and primary care, department of health and human services.(f) Licensees choosing to opt-out of the survey shall submit the completed opt out form described in He-C 801.04, to the State office of rural health and primary care, department of health and human services, via one of the following:(g) Information contained in the opt-out forms shall be kept confidential in the same accord with the survey form results, pursuant to RSA 126-A:5XVIII-a.(c).N.H. Admin. Code § Med 608.01
#4745, eff 1-25-90, EXPIRED 1-25-96
New. #6472, eff 3-25-97; ss by #6828, eff 8-11-98; ss by #8678, eff 7-11-06; ss by #9900, eff 4-12-11 (see Revision Note at chapter heading for Med 600); ss by #10331, eff 5-8-13
Amended by Volume XXXVI Number 10, Filed March 10, 2016, Proposed by #11049, Effective 3/2/2016, Expires 3/2/2026.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.Amended by Volume XLII Number 41, Filed October 13, 2022, Proposed by #13444, Effective 9/13/2022, Expires 9/13/2032