Section Nat 402.05 - Two-Part Application Form(a) Applicants for renewal of licensure shall complete, sign and date a 2-part renewal application form provided by the board.(b) The information entered on both parts of the renewal application form shall be typewritten or legibly printed in ink.(c) Renewal applicants shall complete the renewal application form by completing in writing or by check mark, as applicable.(d) On the first part of the application form renewal applicants shall provide the following information:(1) First name, middle initial, and last name;(4) An indication as to whether the renewal applicant is currently in practice;(5) An indication as to whether the renewal applicant is renewing a specialty license;(6) Business or other mailing address by name of business, if any, street number and name, city or town, state, and zip code; and(7) Business telephone number, if any.(e) Also on the first part of the renewal application form applicants shall indicate, using the "yes" and "no" boxes provided: (1) Whether, since the issuance of the license being renewed, they have been refused a professional license or other authorization to practice naturopathic medicine by a regulatory body of any state, country, or other regulatory jurisdiction;(2) Whether, since the issuance of the license being renewed, they have had a professional license or other authorization to practice naturopathic medicine revoked or suspended by a regulatory body of any state, country, or other regulatory jurisdiction;(3) Whether, since the issuance of the license being renewed, they have had disciplinary action other than action reportable under paragraphs (1) and (2) taken against them by any state, country or other regulatory jurisdiction;(4) Whether, since the issuance of the license being renewed, they have entered into a settlement agreement or consent decree to resolve a complaint of misconduct or a disciplinary charge;(5) Whether, since the issuance of the license being renewed, any of their professional licenses have been the subject of a disciplinary proceeding, settlement agreement, or consent decree undertaken or issued by any professional licensing authority in any jurisdiction;(6) Whether, since the issuance of the license being renewed, any disciplinary action has been taken against them by any hospital or other health care facility, or international, national, state, or local professional association;(7) Whether, since the issuance of the license being renewed, any malpractice claim or a malpractice law suit has been brought against them;(8) Whether, since the issuance of the license being renewed, certification by NCCAOM or ACNO has been suspended or revoked; and(9) Whether, since the issuance of the license being renewed, they have been convicted of a felony or a misdemeanor.(f) Renewal applicants shall sign and date the first part of the renewal application form below the following statement preprinted on the form: (1) The information provided on both parts of the renewal application form and the documentation provided to support the renewal application are true, accurate, complete and unaltered; and(2) The renewal applicant acknowledges that, pursuant to RSA 641:3, the knowing making of a false statement on the renewal application form is punishable as a misdemeanor."(g) A renewal applicant's signature as set forth in (f) above shall constitute the renewal applicant's acknowledgement of his or her understanding that any untrue, inaccurate, incomplete or altered information made knowingly on either part of the renewal application form or included in the supporting materials is grounds for punishment pursuant to RSA 641:3.(h) On the second part of the renewal application form, renewal applicants shall provide: (2) Their home addresses by street number and name, city or town, state, and zip code; and(3) Their home telephone numbers.(i) On the second part of the renewal application form renewal applicants shall indicate, using the "yes" and "no" boxes provided, whether: (1) They are now being or anticipate being investigated for possible misconduct by a regulatory body of any state or country or other regulatory jurisdiction;(2) They anticipate that any of their professional licenses soon will be the subject of a disciplinary proceeding, settlement agreement, or consent decree undertaken or issued by any professional licensing authority in any jurisdiction;(3) Since the issuance of the license being renewed, they have voluntarily surrendered a license or other authorization to practice naturopathic medicine, or allowed such a license or authorization to lapse, to avoid disciplinary investigation or action;(4) Since the issuance of the license being renewed, they have been investigated for possible misconduct by a hospital or other health care facility, or international, national, state, or local professional association;(5) Since the issuance of the license being renewed, they have developed any physical, mental, addictive or other condition that negatively affects their ability to practice naturopathic medicine;(6) Since the issuance of the license being renewed, they have developed any physical, mental, addictive, or other condition for which continuing remedial or therapeutic action is required to ensure their continuing ability to practice naturopathic medicine; and(7) They carry a DEA number in New Hampshire and, if so, the number itself.(j) If the applicant answers "yes" to any of the questions described in (i)(1)-(6) above, he or she must provide a written explanation of the circumstances including any relevant documentation.N.H. Admin. Code § Nat 402.05
Amended by Volume XXXVII Number 23, Filed June 8, 2017, Proposed by #12176, Effective 5/17/2017, Expires 5/17/2027.