Board of Medical Imaging and Radiation Therapy - an official New Hampshire Government website
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Application Forms

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

Application Form Instructions pdf file

Initial License Application Form pdf file

State Verification Form pdf file

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.

Documents Required for Each License Type

Limited X-Ray Machine Operator:

  1. Application;
  2. Explanation of any "Yes" answers;
  3. Letter of Verification from any state that issued a license or authorization;
  4. Criminal Offender Record Report issued by each state where the applicant has resided or been licensed in the past 6 years (dated within the past 6 months);
  5. Copy of Certification Card from:
    • The American Registry of Radiologic Technologists (ARRT);
    • The American Chiropractic Registry of Radiologic Technologists (ACRRT);
    • The American Society of Podiatric Medical Assistants (ASPMA); or
    • The International Society for Clinical Densitometry (ISCD)

Magnetic Resonance Technologist:

  1. Application;
  2. Explanation of any "Yes" answers;
  3. Letter of Verification from any state that issued a license or authorization;
  4. Criminal Offender Record Report issued by each state where the applicant has resided or been licensed in the past 6 years (dated within the past 6 months);
  5. Copy of Certification Card from:
    • The American Registry of Radiologic Technologist; or
    • The American Registry of Magnetic Resonance Imaging Technologists (ARMRIT)

Nuclear Medicine Technologist:

  1. Application;
  2. Explanation of any "Yes" answers;
  3. Letter of Verification from any state that issued a license or authorization;
  4. Criminal Offender Record Report issued by each state where the applicant has resided or been licensed in the past 6 years (dated within the past 6 months);
  5. Copy of Certification Card from:
    • The American Registry of Radiologic Technologists; or
    • Nuclear Medicine Technology Certification Board (NMTCB)

Radiation Therapist:

  1. Application;
  2. Explanation of any "Yes" answers;
  3. Letter of Verification from any state that issued a license or authorization;
  4. Criminal Offender Record Report issued by each state where the applicant has resided or been licensed in the past 6 years (dated within the past 6 months);
  5. Copy of Certification Card from:
    • American Registry of Radiologic Technologists

Radiographer:

  1. Application;
  2. Explanation of any "Yes" answers;
  3. Letter of Verification from any state that issued a license or authorization;
  4. Criminal Offender Record Report issued by each state where the applicant has resided or been licensed in the past 6 years (dated within the past 6 months);
  5. Copy of Certification Card from:
    • The American Registry of Radiologic Technicians; or
    • Cardiovascular Credentialing International as an RCES or RCIS

Radiologist Assistant:

  1. Application;
  2. Explanation of any "Yes" answers;
  3. Letter of Verification from any state that issued a license or authorization;
  4. Criminal Offender Record Report issued by each state where the applicant has resided or been licensed in the past 6 years (dated within the past 6 months);
  5. Copy of Certification Card from:
    • The American Registry of Radiologic Technicians; or
    • Board of Radiology Physician Assistants
  6. Clinical Protocols signed by the supervising radiologist specifying:
    • Procedures that are performed by the radiologist assistant;
    • Levels of radiologist supervision; and
    • The locations of practice designated by the supervising radiologist

Sonographer:

  1. Application;
  2. Explanation of any "Yes" answers;
  3. Letter of Verification from any state that issued a license or authorization;
  4. Criminal Offender Record Report issued by each state where the applicant has resided or been licensed in the past 6 years (dated within the past 6 months);
    • Copy of Certification Card from:
    • The American Registry of Radiologic Technicians; or
    • The American Registry of Diagnostic Medical Sonography (ARDMS); or
    • Cardiovascular Credentialing International (CCI)

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Office of Professional Licensure and Certification
121 South Fruit Street |  Concord, NH 03301