Section Plc 308.06 - Information Required for Renewal Applications The applicant shall provide the following information on the form identified in Plc 308.05(b)(1):
(a) The applicant's profession and the license number and expiration date of the license;(b) For individuals, the following: (1) The applicant's full legal name, including any suffix such as "Jr." or "III", and any name(s) under which the applicant holds or has held a professional license;(2) The applicant's date of birth by month, day, and year;(3) The applicant's social security number or other U.S. taxpayer identification number, as required by RSA 161-B:11, VI-a and 42 U.S.C. 666(a)(13);(4) The applicant's designated email address, home physical address, and home mailing address, if different;(5) The applicant's home or other personal telephone number;(6) The name, physical address, and telephone number of the applicant's office or other place of business;(7) If the applicant routinely practices in more than one location, the name of each such location and, for each:a. The business address and telephone number; andb. Whether the applicant is an employee, a subtenant subletting space, an independent contractor, or the owner of the business;(8) Whether the applicant is on active military duty or is a military spouse, and whether the applicant is applying for facilitated licensure;(9) The following information, to be used solely for purpose of workforce data analysis, provided that "prefer not to answer" shall be an acceptable response to any question:a. Highest level of education, whether or not related to the profession in which licensure is being sought;b. Relative to the applicant's employment status, whether the applicant is: 1. Actively working in a position that requires the license being applied for;2. Actively working in a position in the same profession that does not require this license;3. Actively working in a position in a different profession;4. Not currently working; orc. Relative to the applicant's employment plans for the next 2 years, whether the applicant intends to:1. Increase hours in a field related to this license;2. Decrease hours in a field related to this license;3. Seek employment in a field unrelated to this license;6. Not sure or plans unknown;d. Identification of the specialty, field, or area of practice in which the applicant spends the most professional time;e. Whether the applicant uses telehealth to deliver services to patients;f. The state in which the applicant's primary practice is located, if applicable;g. The 5-digit zip code of the applicant's primary practice location, if applicable;h. Relative to the applicant's current employment arrangement at their principal practice location, whether the applicant is:1. Self-employed or a consultant;4. In temporary employment or Locum Tenens;i. In the applicant's primary employment or practice, whether the applicant's primary role is that of: 2. Clinical practitioner;3. Faculty or other educator;(10) For applicants in any health care profession:a. Identification of the practice setting at the applicant's primary practice location;b. What population groups the applicant provides services to;c. An estimate of the number of hours per week the applicant spends at their primary practice location; andd. An estimate of the number of hours per week the applicant spends in direct patient care; (11) For applicants in any health care profession, whether the applicant intends to practice in New Hampshire more than 50% of the time, whether in-person or by telehealth; and(12) Any other profession-specific information required by applicable law, such as proof of certification by, or registration with, a regional or national credentialing organization, to the extent not otherwise covered by this section;(c) For entities, the following: (1) The applicant's full legal name as shown on the document(s) that created the entity and each name under which the applicant does business in New Hampshire;(2) The type of entity the applicant is, such as a corporation, limited liability corporation, professional association, partnership, or other form;(3) The entity's date and state of formation;(4) The employer identification number or other federal tax ID number assigned to the applicant by the U.S. Internal Revenue Service;(5) The applicant's primary location address in New Hampshire and New Hampshire mailing address, if different;(6) The applicant's main telephone number;(7) The applicant's designated email address;(8) The name, telephone number, and email address of the authorized signer and the name, telephone number, and email address of each contact individual, if other than the authorized signer;(9) Such information as is required by applicable law on partners, officers, directors, and similar individuals having responsibility for or control over the applicant; and(10) Any additional information required for entities by applicable law;(d) Identification of all jurisdictions where the applicant is currently licensed and, for each, the date of most recent licensure and status of the license;(e) A "yes" or "no" answer to the following questions regarding the applicant's background and character, provided that "not previously reported" shall not include anything that was not required to be submitted by Plc 304.03(e):(1) Whether during the past 27 months or not previously reported, the applicant has been found guilty of or entered a plea of no contest to any felony or misdemeanor;(2) Whether during the past 27 months or not previously reported, the applicant has been the subject of any disciplinary action by any professional licensing authority;(3) Whether during the past 27 months or not previously reported, the applicant has been denied a license or other authorization to practice in any jurisdiction;(4) Whether during the past 27 months or not previously reported, the applicant has surrendered a license or other authorization to practice issued by any jurisdiction in order to avoid or settle disciplinary charges;(5) Whether the applicant is now or has any reason to believe that the applicant will soon be the subject of a disciplinary proceeding, settlement agreement, or consent decree undertaken or issued by a professional licensing board of any jurisdiction;(6) Whether during the past 27 months or not previously reported, any malpractice claim has been made against the applicant;(7) Whether during the past 27 months or not previously reported, the applicant has, for disciplinary reasons, been put on administrative leave, been fired for cause other than staff reductions from a position at the applicant's place of employment, or had any privileges limited, suspended or revoked in any professional setting; and(8) Whether during the past 27 months or not previously reported, the applicant has committed any act(s) that would violate the laws or rules, or both, that govern the practice of the profession in which the applicant is licensed;(f) Whether the applicant has a DEA registration number and, if so, what the number is;(g) Whether the applicant stores, administers, or dispenses controlled drugs in a setting that is not regulated under RSA 318 relative to pharmacists and pharmacies;(h) For applicants in any health care field, whether the applicant has an ownership interest in any diagnostic or therapeutic service(s) or company(ies), and if so the name and address of each company and the specific diagnostic or therapeutic services provided by the company, to comply with RSA 125:25-c; and(i) Whether the applicant consents to the disclosure to third parties of:(1) For individuals, any or all of the applicant's contact information; or(2) For entities, the entity's designated email address.N.H. Admin. Code § Plc 308.06
Derived from Number 15, Filed April 13, 2023, Proposed by #13606, Effective 5/1/2023, Expires 5/1/2033.Amended by Number 24, Filed June 13, 2024, Proposed by #13955, Effective 5/3/2024, Expires 5/3/2034 (see Revision Note #2 at chapter heading for Plc 300).