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Board of Medical Imaging and Radiation Therapy Application Forms

Forms for licenses issued by the Board of Medical Imaging and Radiation Therapy

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To apply for an initial New Hampshire license or to reinstate a New Hampshire license, use our online application: https://www.app-support.nh.gov/licensing/

In addition to the application form you will also need to read the Laws and Rules that govern those individuals licensed by the Board of Medical Imaging and Radiation Therapy.

Registration Process: RSA 328-J:22

This registration process is for those individuals who meet the description of persons who have been engaged in the practice of medical imaging or radiation therapy, other than a radiologist assistant, who do not hold a current certification and registration to form a certification organization approved by the board so that they may continue to practice in the modality of medical imaging or radiation therapy in which they are currently employed provide they register with the Board.

These individuals must obtain licensure before January 1, 2020 or cease practicing.

Submit to the Board an original statement that is signed and dated containing the following information:

  • Name Address and Phone Number of the Individual Who is Registering;
  • Name Address and Phone Number of Employer;
  • Name Address and Phone Number of the Individual's Supervisor (Supervisor is to be a licensed practitioner); and
  • A description of what medical imaging services the registrant is performing.

Once the all required information is received, the individual will be considered registered. A list of those individuals who are registered will be placed on the Board’s web site. The name of the Registrant, the place of employment, the individual’s supervisor, and the services they are providing will be listed on the Board’s web site. No other documentation will be provided. The web site will be evidence of registration.

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