An applicant for licensure renewal shall supply the following
information on the "Application for Renewal of License" form, effective October
2017:
(a) The renewal applicant's:
(1) Full name;
(2) New Hampshire license number;
(3) Business physical address and business
telephone number;
(4) Residential
address and residential telephone number;
(5) Mailing address, if different from
business and residential addresses;
(6) E-mail address, if any;
(7) Fax number, if any;
(8) Any previously used names or maiden
names;
(9) Date of birth;
and
(10) National provider
identifier, if known;
(b) If not previously provided to the board,
the renewal applicant's social security number, written immediately below the
following preprinted statement:
"The Board of Chiropractic Examiners is required by
RSA
161-B:11 to obtain your social security
number for the purpose of child support enforcement. Except for its use in
child support enforcement, your social security number will not be used by the
Board of Chiropractic Examiners and will be held confidential."
(c) The renewal applicant's
height, weight, eye color and hair color;
(d) Whether the renewal applicant has any
physical, mental or other condition or disability affecting the applicant's
ability to practice chiropractic;
(e) Whether the renewal applicant has any
physical, mental or other condition or disability for which continuing remedial
or therapeutic action is required to ensure the applicant's continuing ability
to practice chiropractic;
(f)
Whether the renewal applicant uses alcohol or controlled or non-controlled
drugs in a manner affecting the applicant's ability to practice
chiropractic;
(g) Whether the
renewal applicant has since last issuance or renewal of his or her New
Hampshire license been convicted of a felony or misdemeanor;
(h) If the answer to (d), (e), (f), or (g) is
affirmative, a summary statement explaining the answer and specifying as
applicable:
(1) The physical, mental or other
condition or disability;
(2) The
remedial or therapeutic action;
(3)
The use of alcohol or controlled or non-controlled drugs; and
(4) The charges of which the renewal
applicant was convicted, the conviction date, and the sentence imposed or other
disposition;
(i) Whether
the renewal applicant currently holds any professional license, certification
or registration to practice any method of healing other than
chiropractic;
(j) If the answer to
(i) is affirmative, the type of license(s), certification(s) or registration(s)
held and the issuing jurisdiction or state;
(k) Whether the renewal applicant currently
holds, or has been issued since last issuance or renewal of his or her New
Hampshire license, any license to practice chiropractic issued by another
jurisdiction;
(l) For every such
license to practice chiropractic:
(1) The
issuing jurisdiction or state;
(2)
The license date;
(3) The license
number; and
(4) If applicable, the
reason the renewal applicant no longer holds the license;
(m) Whether, since last issuance or renewal
of his or her New Hampshire license, there has been any disciplinary action by
any other jurisdiction against the renewal applicant's chiropractic or other
professional license, certification or registration;
(n) Whether there are now, or have been since
last issuance or renewal of his or her New Hampshire license, complaints made
or investigations conducted in connection with any professional license,
certification or registration previously or currently held by the renewal
applicant;
(o) Whether, to the best
of the renewal applicant's knowledge, there are now, or have been since last
issuance or renewal of licensure, any malpractice claims, settlements or
judgments against the renewal applicant;
(p) Whether a complaint has been brought
against the renewal applicant in any court or professional or business
organization of which he or she is a member; and
(q) If the answer to (m), (n), (o), or (p) is
affirmative, a detailed written explanation of the circumstances.
