Section Phy 402.04 - Licensure Renewal Application Form(a) The renewal application form shall:(1) Be provided by the board; and(2) Contain 3 parts as follows:a. Part one, which shall be available to the public, except for the information required by (c) and (d) below;b. Part 2, which shall be held confidential by the board, except for the information required by (g)(5), (g)(6), and (g)(7) below; andc. Part 3, which is available to the public.(b) The renewal applicant shall: (1) Complete the entire renewal application form using a keyboard or by printing legibly in ink; and(2) Complete all sections of the entire renewal application form or designate them as not applicable.(c) On part one of the renewal application form the renewal applicant shall correct as necessary the home mailing address.(d) Also on part one of the form the renewal applicant shall list the jurisdictions, other than New Hampshire, where the applicant is currently licensed to practice.(e) Also on part one of the form using the "yes" and "no" columns provided, indicate whether: a. During the past 27 months, or if not previously reported, the applicant has been found guilty of, or entered a plea of no contest to, any felony or misdemeanor;b. During the past 27 months, or if not previously reported, the applicant has been the subject of any disciplinary action by any professional licensing authority;c. During the past 27 months, or if not previously reported, the applicant has been denied a license or other authorization to practice in any state or jurisdiction; andd. During the past 27 months, or if not previously reported, the applicant has surrendered a license or other authorization to practice issued by any state or jurisdiction in order to avoid or settle disciplinary charges.(f) Also on part one of the form the renewal applicant shall place his or her signature and the date of signing below the following preprinted statement: "I acknowledge that knowingly making a false statement on this application form is a misdemeanor under RSA 641:2, I. I certify that the information I have provided on all parts of the application form and in the documents that I have personally submitted to support my application is complete and accurate to the best of my knowledge and belief. I also certify that I have read the statute and the rules of the Board and promise that, if I am licensed, I will abide by them."
(g) On part 2 of the form a renewal applicant shall provide the applicant's: (2) Home physical address;(3) Home phone number or personal cell phone number;(4) Home mailing address;(5) Place of employment name, if any;(6) Place of employment mailing address, if any;(7) Place of employment phone number, if any; and(8) E-mail address at which the applicant wishes to receive correspondence from the board.(h) The renewal applicant shall use the boxes provided to indicate which of the following addresses, if any, the board is permitted to make available to the public: (1) Home mailing address;(3) Place of employment mailing address; and(i) The renewal applicant shall designate by checking one of the appropriate boxes if the applicant wishes to receive notification from the board by e-mail or regular mail.(j) The renewal applicant shall verify his or her social security number and make any necessary corrections to the preprinted number by striking through the incorrect number and writing the corrected number under the following preprinted statement: "The Governing Board of your profession 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 Governing Board is required to obtain your social security number for the purpose of child support enforcement and in compliance with RSA 161-B:11. This collection of your social security number is mandatory."
(k) Also on part 2 of the renewal application form the renewal applicant shall indicate using the "yes" and "no" columns provided, indicate whether: (1) The applicant has any reason to believe that the applicant will soon be the subject of a disciplinary proceeding, settlement agreement or consent decree undertaken or issued by a professional licensing board or any state or jurisdiction;(2) During the past 27 months, or if not previously reported, any malpractice claim has been made against the applicant;(3) During the past 27 months, or if not previously reported, the applicant has for disciplinary reasons been put on administrative leave, been fired for cause other than staff reductions from a position at his or her place of employment, or had any privileges limited, suspended or revoked in any: b. Health care institution;c. Home health care agency;d. Educational institution; ore. Other professional setting;(4) During the past 27 months, or if not previously reported, the applicant has been denied the privilege of taking an examination required for any professional licensure; and(5) During the past 27 months, or if not previously reported, the applicant has any physical, mental or emotional condition, or any alcohol or substance abuse problem, which could negatively affect the applicant's ability to practice the profession for which licensure is sought.(l) On part 3 of the form the renewal applicant shall:(1) Place his or her full name and current New Hampshire license number; and(2) Indicate, by using the check box provided, the allied health profession of licensure.(m) Also on part three of the form the renewal applicant shall use the designated columns to report the following information about each continuing professional education course or professional activity constituting maintenance of continuing competence completed since the issuance of the initial license or the last licensure renewal: (1) Its beginning and ending dates;(3) The name of its sponsor or provider;(4) The clinical hours attributable to it;(5) The other hours attributable to it; and(6) The total number of hours attributable to it.(n) Also on part 3 of the form the renewal applicant shall:(1) Show in the space provided the total hours of continuing professional education and professional activity completed;(2) Use the designated columns to report the same information required by (h) above for each course or professional activity he or she anticipates will be completed between November 1 and December 31; and(3) Show in the space provided the total hours of continuing professional education and professional activity anticipated to be completed between November 1 and December 31.N.H. Admin. Code § Phy 402.04
#9456, eff 4-17-09; ss by # 10061, eff 12-23-11; ss by #10203, eff 19-19-12; ss by #10402, eff 8-23-13
The amended version of this section by New Hampshire Register Volume 37, Number 06, eff. 1/20/2017 is not yet available.