Section Den 301.04 - Application for Dentist License Registration and Renewal(a) Each applicant for registration and renewal of a license to practice dentistry in the state of New Hampshire shall provide the following on the dentist "Application for Registration and License Renewal" form, effective April 2017 and available on the board's website:(1) Applicant's mailing address if changed;(3) Applicant's license number;(4) Whether the applicant's license is active or inactive;(5) Applicant's original date of New Hampshire license;(6) Whether the applicant has practiced in the current biennium;(7) Whether the applicant practices as a specialist;(8) A listing of other states where the applicant holds a dental license, if any;(9) A listing of hospitals where the applicant holds staff privileges, if any;(10) Applicant's primary residence and telephone number;(11) Applicant's practice addresses, telephone numbers, and primary email address either business or personal;(12) Whether the applicant:a. Has been convicted of any felony, misdemeanor, or driving under the influence of alcohol or drugs which has not been annulled;b. Has ever been convicted of the illegal practice of dentistry;c. Has ever been denied dental licensure;d. Currently has or ever has had any professional license subjected by any professional licensing body in any jurisdiction or state to any investigation, sanction, or disciplinary action, including but not limited to revocation, suspension, probation or stayed probation, limitation or restriction, fine, reprimand, denied renewal, voluntary or involuntary relinquishment, or required submission to care, counseling, supervision, or further education;e. Possessed a dental license that has been revoked, suspended, placed under probation or stayed probation, restricted, not renewed, voluntarily or involuntarily relinquished, or otherwise sanctioned, or has disciplinary actions pending in any jurisdiction or state;f. Has ever been or is currently named as a party in any malpractice or professional liability claim or lawsuit or has any pending;g. Has had hospital privileges revoked, suspended, restricted, denied, not renewed or involuntarily relinquished; andh. Has ever had a DEA license revoked, suspended, denied, placed on probation, restricted or otherwise sanctioned by a state or federal licensing/regulatory board or agency, or which is currently involved in an investigation or disciplinary process;(13) Whether the applicant has a physical or mental illness or other condition, or addiction to alcohol, narcotics or other mind altering drugs which impairs the applicant's ability to practice dentistry;(14) Whether the applicant uses general anesthesia, deep sedation or moderate sedation on an outpatient basis for dental patients in New Hampshire;(15) Whether the applicant, if he or she holds a moderate sedation permit, has documented 12 cases in the biennium or 4 hours of continuing education in sedation training;(16) Excluding an in-office ancillary services, whether the applicant has an ownership in any entity which provides diagnostic or therapeutic services, and if so, attach a list;(17) Whether the applicant has completed 40 hours of continuing education, at least 30 of which are clinical in nature, within the 2 years immediately preceding the application;(18) Whether the applicant's BLS-HCP is current; and(19) Whether the applicant has registered with the New Hampshire Controlled Drug Prescription Health and Safety Program (PDMP), as required in RSA 318-B:33, II and Ph 1503.01(a), if the applicant possesses a DEA number to prescribe schedules II-IV controlled substances. If the applicant possesses a DEA number, the applicant shall provide the number to the board.(b) Failure to register shall constitute professional misconduct within the meaning of RSA 317-A:17, II and shall be grounds for disciplinary action. A licensee shall not engage in the prescribing or dispensing of controlled substances in schedules II-IV without having registered with the New Hampshire PDMP.(c) The form shall be completed and attested to by the applicant and filed with the board. Deceptive or false statements, knowingly made by the applicant shall result in denial of license. By signing the form, the applicant shall waive any confidentiality regarding disclosure to the board from any other jurisdiction about any pending complaints or action being taken against the applicant's license to practice dentistry and consents to a criminal background check.(d) If the answer to (a) (17) is 'no', then a 30-day extension period for late registration shall be available to complete the requirement.(e) Pursuant to Den 301.08, there shall be a fee for late biennial registration. The form used shall be the same as the regular renewal form.(f) Applicants for renewal may complete their renewal applications online at https://nhlicenses.nh.gov.(g) Pursuant to RSA 126-A:5, XVIII-a.(a) and RSA 317-A:12-a, dentists 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, pursuant to He-C 801.(h) The board shall provide dentists 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 at https://www.dhhs.nh.gov/dphs/bchs/rhpc/data-center.htm.(i) Dentists choosing to opt-out of the survey shall complete and submit the "New Hampshire Health Professions Survey Opt-Out Form," revised June 2020, to the state office of rural health and primary care, department of health and human services, via one of the following:(j) 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:5XVIII-a(c).N.H. Admin. Code § Den 301.04
Amended byVolume XXXIV Number 46, Filed November 13, 2014, Proposed by #10689, Effective 10/7/2014, Expires10/7/2024.Amended by Volume XXXV Number 23, Filed June 11, 2014 , Proposed by #10824, Effective 5/6/2015, Expires5/6/2025.Amended by Volume XXXVI Number 01, Filed January 7, 2016, Proposed by #10991, Effective 12/9/2015, Expires 12/9/2025.Amended by Volume XXXVII Number 50, Filed December 14, 2017, Proposed by #12428, Effective 12/6/2017, Expires 12/6/2027.Amended by Volume XL Number 46, Filed November 12, 2020, Proposed by #13116, Effective 10/9/2020, Expires 10/9/2030.