N.H. Admin. Code § Ch 402.05

Current through Register No. 50, December 12, 2024

Section Ch 402.05 - Renewal Application Form

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.

N.H. Admin. Code § Ch 402.05

(See Revision Note before Chapter heading Ch 100) #4671, eff 9-7-89; ss by #5624, eff 5-18-93, EXPIRED: 5-18-99

New. #8739, eff 10-11-06; ss by #9358, eff 1-10-09

Amended by Volume XXXVII Number 10, Filed March 9, 2017, Proposed by #12107, Effective 2/21/2017, Expires8/20/2017.

Amended by Volume XXXVII Number 50, Filed December 14, 2017, Proposed by #12431, Effective 12/8/2017, Expires 12/8/2027.