Get Nh Provider License Application 2022-2025

Filling out the NH Provider License Application online is a straightforward process that helps ensure you meet the necessary requirements to become a licensed provider in New Hampshire. This guide will walk you through each section of the form, providing clear instructions to assist you in completing your application accurately.

Follow the steps to complete your application successfully.

1. Press the ‘Get Form’ button to access the NH Provider License Application and open it in your preferred document editor.
2. In Section 1, select the type of application by checking one box. You will need to choose between 'New,' 'Renewal,' 'Level Change,' or 'Lapsed' and identify the license type such as EMR, EMT, AEMT, Paramedic, and others.
3. Provide your full legal name in the 'Applicant Information' section. Fill in the required fields, including first name, middle initial, last name, mailing address, preferred phone number, date of birth, gender, and personal email address.
4. Attach legible copies of your current National Registry Certification in the designated section. Make sure to include your National Registry expiration date and number.
5. In Section 3, specify your affiliation status. You can either attest to being affiliated with a licensed NH EMS unit or indicate non-affiliation by checking the appropriate box.
6. Sign and date the application in Section 4, where you certify all information is complete and correct. Ensure that you understand the consequences of any material falsifications.
7. If you are an apprentice applicant or are applying for First Responder Naloxone Provider status, make sure to fill out and sign Section 5 appropriately.
8. After completing all sections and reviewing your information for accuracy, save your changes. You may then proceed to download, print, or share the form as needed.

To ensure timely processing of your application, complete the NH Provider License Application online today.