Section Med 301.03 - Application for an Unrestricted Permanent License(a) Applicants for an unrestricted permanent license shall provide, or cause to be provided, the following on a form supplied by the board: (1) The applicant's name, including any names previously used;(2) The applicant's residence and business addresses and telephone numbers, business e-mail address and business fax number;(3) The applicant's date of birth, place of birth and social security number required pursuant to 45 CFR Part 60.8 and RSA 161-B:11, VI-a. The applicant shall furnish his or her social security number on the line provided below the following preprinted statement: "The board will deny licensure if you refuse to submit 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."
(4) The applicant's educational history including the names of all institutions attended, the dates of attendance and the degree awarded;(5) A certification of medical education received directly from and verified by FCVS;(6) If the applicant graduated from a medical school outside the United States or Canada: a. Certified copies of an official transcript of grades and proof of graduation with certified English translation received directly from and verified by FCVS; andb. Verification received directly from FCVS that the applicant holds a current certification from the Educational Commission of Foreign Medical Graduates (ECFMG);(7) A listing of all institutions in which the applicant has pursued post graduate training and a written verification received directly from FCVS that the applicant has completed at least 2 years of training which meet the requirements of Med 302.01;(8) Verification received directly from FCVS that the applicant has passed one of the licensure examinations listed under Med 303.01;(9) A listing of every state in which the applicant holds or has ever held a license and clearances of those licenses received directly from the licensure authority;(10) Disclosure of whether the applicant is board certified and if so, a certified copy of that certification;(11) Disclosure of whether the applicant has ever lost or been denied board certification and if so, an explanation for the circumstances;(12) Disclosure of whether the applicant has ever been subject to a claim for malpractice and if so, the circumstances of that claim;(13) Disclosure of whether the applicant has ever taken an examination or applied for licensure under a different name;(14) Disclosure of whether the applicant has ever failed any medical licensing examination or been denied the privilege of finishing or been accused of cheating or improper conduct during any required examination, and, if so, the circumstances involved;(15) Disclosure of whether the applicant has ever been denied a medical license and, if so, the circumstances of that denial;(16) Disclosure of whether the applicant has ever had hospital privileges, employment, or appointment at any health care institution denied, limited, suspended, or revoked or whether the applicant has ever resigned in lieu of such actions and if so, the circumstances involved;(17) Disclosure of whether the applicant is currently under investigation or whether any disciplinary action has been taken against the applicant during the past 10 years by any governmental authority, hospital, or health care facility or by any professional medical association, and, if so, the circumstances involved;(18) Disclosure of whether the applicant has ever voluntarily surrendered a license to practice medicine in lieu of facing disciplinary action or ever withdrawn an application for licensure, hospital privileges or appointment for any reason and if so the circumstances involved;(19) Disclosure of whether the applicant has ever been a defendant in a criminal proceeding and the circumstances of that criminal proceeding;(20) Disclosure of whether the applicant has ever lost the privilege to possess, dispense, or prescribe controlled substances or been investigated by any state or federal drug enforcement agencies;(21) Disclosure of 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;(22) Disclosure of 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;(23) Disclosure of whether the applicant has not been actively engaged in the practice of clinical medicine within the past 12 months;(24) A certified copy of the applicant's birth certificate or passport received directly from FCVS;(25) A listing of all professional activities pursued including the dates of such activities since the applicant graduated from medical school;(26) Original letters of reference, on letterhead and addressed to the board, from: a. The chief medical officer or president of the medical staff in every hospital in which the applicant currently holds staff privileges; orb. Letters of reference from 2 practicing physicians;(27) A recent, full face, 2 x 3 inch photograph of the applicant;(28) The applicant's notarized signature attesting to the accuracy of the information provided; and(29) If applicable, a copy of the applicant's current Drug Enforcement Administration (DEA) certificate.(b) Applicants shall include the application fee required in Table 3.6.1 in Med 306.01.(c) A temporary license, valid for only 6 months, shall be issued pursuant to RSA 329:14, III only to applicants for a full New Hampshire license who have met the requirements of Med 301.03(a) and (b) above, excluding Med 301.03(a)(5), Med 301.03(a)(6), Med 301.03(a)(7), Med 301.03(a)(8) and Med 301.03(a)(24). Applicants shall not begin to practice until such time as they receive a temporary license.(d) Applicants for temporary license shall also provide, or cause to be provided, the following: (1) Evidence of qualifications as follows: a. Proof of a full, unrestricted medical license in another state received directly from the state licensing authority indicating that the applicant's license covers the dates in which he or she is practicing in New Hampshire; orb. Certified copies of a medical degree diploma, proof of 2 years of postgraduate training which meet the requirements of Med 302.01, and proof that the applicant has passed one of the licensure examinations listed under Med 303.01;(2) Proof that the applicant has applied to the FCVS with full intent to complete the FCVS process; and(3) The temporary license fee specified in Table 3.6.1 in Med 306.01.N.H. Admin. Code § Med 301.03
#4970, eff 11-8-90; ss by #5908, eff 10-7-94; ss by #6576, eff 9-15-97; amd by #7591, eff 11-14-01; amd by #8068, eff 4-10-04; amd by #8096, eff 6-5-04; amd by #8662, INTERIM, eff 6-16-06, EXPIRED: 12-13-06 (paragraphs (a)(1)-(27) and (b)); ss by #8945, eff 7-18-07; ss by #9900, eff 4-12-11 (see Revision Note at chapter heading for Med 300)
Amended by Volume XL Number 7, Filed February 13, 2020, Proposed by #12972, Effective 1/10/2020, Expires 1/10/2030