N.H. Admin. Code § Psyc 404.01

Current through Register No. 50, December 12, 2024

Section Psyc 404.01 - Reinstatement Requirements

(a) If a license is not renewed, it shall be reinstated upon approval by the board of a complete application seeking such reinstatement submitted not later than 6 months after the date of license expiration.

(b) Licensees wishing to reinstate a license that has expired shall submit a "Reinstatement Application Form", supplied by the board, containing the following:

(1) Name;

(2) Office name;

(3) Residence and business addresses and telephone numbers;

(4) Email address;

(5) Date and place of birth;

(6) Social security number, as required by NH RSA 161-B:11;

(7) A list of all states where the applicant holds or ever held a license to practice psychology;

(8) Disclosure, and explanation where applicable, of the following information:

a. If any malpractice claim has been made against the applicant, regardless of whether a lawsuit was filed in relation to the claim, or whether a malpractice claim has been settled on the applicant's behalf in the last ten years. If the answer to this question is yes, applicants shall complete the "Report of Malpractice Claims or Suits Filed" form, described in (d) below;

b. If the applicant has ever applied for licensure or to sit for an examination, or taken an examination, under a different name;

c. If the applicant has ever been denied the privilege of taking or finishing an examination, or been accused of cheating or improper conduct during an examination, since the applicant graduated from high school;

d. If the applicant has ever failed any national licensure examination, or any part of that examination or state board examination, even if the applicant later passed that examination;

e. If the applicant has been denied a psychology license, certificate, or registration anywhere for any reason;

f. If the applicant has ever had staff privileges, employment or appointment in a hospital or other healthcare institution denied, limited, suspended or revoked, or if the applicant has ever resigned from a medical staff in lieu of disciplinary action;

g. If the applicant has any formal disciplinary charges pending or if any disciplinary action has been taken against the applicant by any psychology licensing board, any health care facility, or any psychological professional association;

h. If the applicant voluntarily surrendered a license to engage in the practice of psychology in lieu of disciplinary action;

i. If the applicant has ever been a defendant in a criminal proceeding including driving while under the influence or driving while suspended, which has not been annulled by a court, but not including traffic offenses not classified as misdemeanors or felonies;

j. If the applicant has ever had or currently has a mental illness or other disorder which impaired his or her ability to practice psychology, and if so, the treatment received and the outcome of such treatment;

k. If the applicant is now, or has been during the last five years, dependent upon alcohol or habituating drugs or undergone treatment for such;

l. An indication of the applicant's anticipated practice location(s), if known;

g. Attestation that the licensee has complied with the continuing education requirements of Psyc 402;

h. Attestation that the licensee has not been found to be abusive towards any child or elderly person by an administrative agency;

i. A criminal background check processed through the New Hampshire State Police;

j. A representation that the licensee acknowledges that the provision of false information in the application is a basis for disciplinary action by the board; and

k. The fee established by RSA 310-A:1-e;

(9) Documentation of compliance with the continuing education requirements of Psyc 402.01;

(10) A description of collaboration activities pursuant to Psyc 403;

(11) The applicant's dated signature which acknowledges that he or she releases from liability the State of NH, the board and its agents and representatives, and any person furnishing information, records, or documents;

(12) A signed, notarized affidavit stating that the applicant is the person referred to in the application, that he or she has studied the treatment of human ailments for not less than 4 school years, that he or she has received a doctoral degree in psychology, that all the statements in the application are true, and that there are no disciplinary actions pending or brought against the applicant except as disclosed in the application; and

(13) A passport sized photograph of the applicant.

(c) The filing fee established by RSA 310-A:1-e.

(d) Applicants for reinstatement who answer "yes" to (b)(4)a. above shall submit a "Report of Malpractice Claims or Suits Filed" form, supplied by the board, for each such claim filed against the applicant, containing the following:

(1) The name of the claimant;

(2) The name of the defendant;

(3) Whether it is a new claim or suit;

(4) The date the claim or suit was filed or opened;

(5) The court name;

(6) The name of the insurance company;

(7) The docket number;

(8) The claim number;

(9) The date of the incident or alleged incident;

(10) The current legal status of the claim;

(11) The general nature of the claim; and

(12) The applicant's dated signature.

(e) An applicant for reinstatement under this section shall obtain verification from all states where he or she currently holds or has ever held a license to practice psychology, by providing a "Licensure Verification Form", supplied by the board, directly to the licensing entity, containing the following information:

(1) To be supplied by the applicant:

a. The applicant's name;

b. The applicant's mailing address;

c. The applicant's date of birth;

d. The applicant's license number; and

e. The applicant's signature; and

(2) To be supplied by the licensing entity:

a. The name of the licensing entity;

b. The full name of the licensee;

c. The license number;

d. An indication of whether the license is current or expired;

e. The license expiration date;

f. An indication of whether the license is restricted and, if so, an explanation of such restrictions on a separate piece of paper;

g. An indication of whether there has ever been disciplinary action taken against the licensee and, if so, an explanation of such action on a separate piece of paper;

h. Whether there are any currently pending investigations against the licensee and, if so, an explanation of such investigations on a separate piece of paper;

i. The official seal of the licensing entity; and

j. The signature and title of the person completing the form.

N.H. Admin. Code § Psyc 404.01

Derived From Volume XXXVI Number 49, Filed December 8, 2016, Proposed by 12035-B, Effective 11/4/2016, Expires 11/4/2026.