N.H. Admin. Code § Med 401.03 - Renewal Application

(a) The licensee shall complete and file a renewal application provided by the board and tender the renewal fee specified by Med 306.01.

(b) The applicant shall include on the renewal form:

(1) The name and business address and telephone number, business e-mail address and business fax number of renewing licensee;

(2) The home address and telephone number of renewing licensee;

(3) Whether the applicant is currently in active practice;

(4) What specialty the licensee practices and whether the applicant is board certified;

(5) A listing of other states in which the licensee currently holds an active license;

(6) A listing of all hospitals in which the applicant currently holds privileges;

(7) The applicant's US Drug Enforcement Agency (DEA) license number, the state of issuance and the expiration date;

(8) 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 during the past 24 months;

(9) Whether the applicant is currently or has in the past 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);

(10) Whether the applicant is currently suffering from any condition, mental or physical, that impairs the applicant's judgment or that would otherwise adversely affect his or her ability to practice medicine in a competent, ethical and professional manner;

(11) Whether the applicant has been found guilty or pleaded no contest to any felony or misdemeanor charges during the past 24 months;

(12) Whether the applicant has been found guilty or pleaded no contest to any driving under the influence violations or has been subject to an administrative finding for driving under the influence in the past 24 months;

(13) Whether the applicant has been the subject of any investigation or disciplinary proceeding or been reported to the National Practitioners Data Bank (NPDB) during the past 24 months;

(14) Whether the applicant has lost or been denied any hospital privileges or had such privileges restricted in any way during the past 24 months;

(15) Whether any malpractice claims have been made against the applicant during the past 24 months;

(16) If the applicant has answered in the affirmative to any inquiries under (7) - (14), a written explanation of the circumstances which caused the applicant to respond in the affirmative;

(17) Whether the applicant has an ownership interest in an entity which provides diagnostic or therapeutic services. Pursuant to RSA 125:25-c, the applicant shall list all diagnostic and therapeutic services provided by any entity in which the applicant has an ownership interest;

(18) The last 4 digits of the applicant's social security number on the line provided below the following preprinted statement: "The board will deny licensure if you refuse to submit the last 4 digits of 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 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."; and

(19) 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.

(c) An application for renewal which is not completed in its entirety or which does not include payment of the renewal fee shall be returned to the licensee unprocessed with a letter stating the reason(s) for the return.

(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.

(e) The board shall provide licensees with the opportunity to opt out of the survey. Written notice of the opt-out opportunity shall be provided with the renewal application. The opt out form shall be available on the NH state office of rural health and primary care website and the board's website.

(f) Licensees choosing to opt-out of the survey shall submit a 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:

(1) Mail;

(2) Email; or

(3) Fax.

(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:5, XVIII-a(c).

Notes

N.H. Admin. Code § Med 401.03

#4970, eff 11-8-90, EXPIRED: 11-8-96

New. #6517, eff 5-30-97; amd by #7949, eff 9-6-03; amd by #8096, eff 6-5-04; amd by #8429, eff 9-13-05; amd by #8662, INTERIM, eff 6-16-06, EXPIRED: 12-13-06 (paragraphs (a), (b)(2)-(6), (14) and (15), now (15) and (17), and (c)); ss by #8945, eff 7-18-07; ss by #9900, eff 4-12-11 (see Revision Note at chapter heading for Med 400)

Amended by Volume XXXV Number 32, Filed August 13, 2015, Proposed by #10876, Effective 7/8/2015, Expires7/8/2025. Amended by Volume XXXVI Number 10, Filed March 10, 2016, Proposed by #11048, 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 1/10/2030