Current through Register No. 40, October 3, 2024
(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;
(2) Applicant's
name;
(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e. Possessed a dental license that has been
revoked, suspended, placed under probation or stayed probation, restricted, not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; and
h. 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:
(1) Mail;
(2) Email; or
(3) Fax.
(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).
