New Mexico Board Of Nursing PDF Template

New Mexico Board Of Nursing PDF Template

The New Mexico Board of Nursing Attestation of Expired/Lapsed License/Certificate is a crucial document for healthcare professionals whose licenses have not been renewed on time. This form requires individuals to formally declare the status of their licensing and provide necessary details regarding their work history during the lapse period. Completing this form accurately is essential to avoid potential disciplinary actions, so be sure to fill it out by clicking the button below.

Overview

The New Mexico Board of Nursing has a crucial form that requires immediate attention for nurses whose licenses or certifications have expired or lapsed. This attestation necessitates individuals to provide specific details regarding their license status and work history since the expiration. At the outset, the individual must affirm that their certification has indeed lapsed and provide a reason for this lapse. Clear instructions guide the respondent to declare whether they have worked during this period, with separate requirements set for those who have and have not engaged in professional activities in New Mexico or any compact state. Essential information about supervisors, including names and contact details, must be included for verification, along with a record of days or shifts worked. Perhaps most critically, timely submission is non-negotiable; the completed form and any supporting documents are due no later than five business days after submitting a renewal application. Failure to adhere could lead to severe consequences, including potential disciplinary action. Misrepresentation on this form may trigger an investigation, underscoring the importance of accuracy and honesty throughout the process.

New Mexico Board Of Nursing Preview

NEW MEXICO BOARD OF NURSING

ATTESTATION OF EXPIRED/LAPSED LICENSE/CERTIFCIATE

On this _________ day of _______________, 20______, I ___________________________, born on

(Print Name)

________________, swear and affirm as follows:

1.That I allowed my New Mexico License/Certification to expire/lapse. The reason for allowing this to occur is as follows:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Attach additional documents if necessary.

2.Please answer either question A or B below:

a.I attest that I did NOT work any hours/shifts in the State of New Mexico or another compact State, since the date in which my license expired/lapsed: ___________.

(Initial)

OR

b.I attest that I DID work on an expired/lapsed license. __________.

(Initial)

i.Supervisors Name: _____________________________

ii. Supervisors Telephone: (

) ___________________

 

 

 

 

iii.Supervisors email Address: _____________________________

iv.Number of days/shifts worked in the State of New Mexico since the date in which my license expired/lapsed: __________________________

v.I have attached a list or payroll records of all dates and hours worked at a job related to my license/certificate from this day going back to the date when my license/certificate expired. ___________. (This also needs to be signed by your

supervisor).(Initial)

3.I understand this attestation as well as any supporting documents need be returned to the NMBON no later than 5 business days following the date of submission of my renewal application. Failure to provide this attestation within the time period required could result in disciplinary action taken towards my New Mexico licensure/certificate ___________.

(Initial)

I swear or affirm that the above and foregoing representations are true and correct to the best of My information, knowledge, and belief.

____________________

__________________________

______________

Print Name

Signature

Date

Any misrepresentation on this attestation can lead to disciplinary action and will be forwarded to the Compliance Division for investigation.

File Properties

Fact Name Description
Purpose This form certifies that a nursing license or certification in New Mexico has expired or lapsed, documenting the situation.
Governing Laws The form is governed by the New Mexico Nursing Practice Act (NMSA 1978, Chapter 61, Article 3).
Submission Deadline Completed attestations must be returned to the New Mexico Board of Nursing within 5 business days from the renewal application submission.
Work History Applicants must indicate whether they worked on an expired license, providing details if applicable.
Documentation Requirement Attach any necessary supporting documents, like payroll records or lists of shifts worked, especially if the license was used after expiration.
Signature Requirement The form must be signed by the applicant, and if applicable, by the supervisor to validate the work history.
Consequences of Misrepresentation Any false statements can lead to disciplinary actions, including investigations by the Compliance Division.
Initials Initials are required for various sections to confirm understanding and agreement to the statements provided.

Instructions on Utilizing New Mexico Board Of Nursing

Now that you have the New Mexico Board of Nursing form in front of you, it’s important to fill it out accurately and completely. Follow these steps to ensure that your attestation is properly filled and submitted on time.

  1. Write the current date at the top of the form:
    • Fill in the blank space for the day.
    • Fill in the blank for the month.
    • Fill in the year.
  2. Print your name in the designated area:
    • Clearly write your full name.
  3. Provide your birth date:
    • Fill in your birth date in the blank provided.
  4. Explain why your license/certificate expired or lapsed:
    • Write your explanation in the space provided. Be clear and concise.
    • If you need more space, attach additional documents as necessary.
  5. Answer one of the questions a or b:
    • If you did NOT work at all, check the box next to option A and initial.
    • If you DID work on an expired/lapsed license, check option B, and then complete the additional fields:
      • Write your supervisor's name.
      • Provide your supervisor's telephone number.
      • Write your supervisor's email address.
      • Indicate the number of days/shifts worked since your license expired or lapsed.
      • Attach a list or payroll records of all shifts worked and ensure your supervisor signs this document.
      • Initial to confirm completion of this section.
  6. Understand and agree to the terms:
    • Carefully read the statement about returning the attestation and initial to confirm your understanding.
  7. Certify your information as true:
    • Sign your name in the space provided.
    • Print your name again below your signature.
    • Fill in today’s date again.
  8. Submit the completed form:
    • Ensure you send the form to the New Mexico Board of Nursing within 5 business days of your renewal application.

Important Facts about New Mexico Board Of Nursing

What is the purpose of the New Mexico Board of Nursing Attestation of Expired/Lapsed License/Certificate form?

This form is used by individuals who have allowed their nursing license or certification to expire or lapse. It helps the New Mexico Board of Nursing (NMBON) track the status of your license and ensure that you comply with state regulations. The form requires you to provide reasons for the lapse and confirm whether you worked while your license was expired.

Who needs to fill out this form?

If your nursing license or certification in New Mexico has expired or lapsed, you need to complete this form. This includes anyone who has not renewed their license on time and may have worked without a valid license during that period.

What information must I provide on the form?

You will need to list the date your license expired, your reasons for the lapse, and if applicable, details about any work you performed with an expired license. This includes your supervisor’s contact information, the number of days or shifts worked, and documentation to support your claims, such as payroll records.

What happens if I do not submit this form on time?

It is crucial to return this attestation and any supporting documents to the NMBON within five business days after submitting your renewal application. Failing to do so could result in disciplinary action, which may affect your licensure or certification status in New Mexico.

Is there a penalty for misrepresentation on the form?

Yes, any misrepresentation or false statements made on this attestation can lead to disciplinary action. The NMBON may forward the case to the Compliance Division for further investigation, which could jeopardize your nursing license.

What if I have additional documents to attach?

If you need to provide more information or documentation, the form allows you to attach additional documents. Be sure to reference these documents and ensure that they are relevant to your circumstances surrounding the expiration or lapse of your license.

How do I submit the completed form?

Once you have completed the form and gathered any necessary documentation, return the packet to the New Mexico Board of Nursing. Check their official website or contact their office to confirm the preferred submission method, which may include mail, email, or online portals.

Where can I find more information on renewing my nursing license in New Mexico?

For detailed guidance on the renewal process, including fees and additional requirements, visit the New Mexico Board of Nursing’s official website. The website provides resources and contact information in case you have specific questions or need assistance.

Common mistakes

Filling out forms for licensing can feel overwhelming, especially when it comes to crucial institutions like the New Mexico Board of Nursing. Unfortunately, many individuals make mistakes that could lead to delays or complications in the renewal process. One common error is neglecting to provide a clear explanation for why the license or certification expired. The provided space for the reason is not just a formality; it’s an opportunity to explain your situation. Without clarity here, the board might face challenges in understanding your circumstances.

Another frequent mistake involves not properly answering the questions about working during the expired period. Applicants sometimes leave out vital information regarding whether they worked on an expired license, even after clearly indicated instructions. The choice between “I did NOT work” and “I DID work” requires a careful review of your work history to ensure accuracy. Misrepresenting any of these details can lead the board to question your integrity.

A lack of thoroughness can also impact the completion of the supervisor’s section. Individuals often forget to include the supervisor's name, contact number, and email. This information acts as a verification point for the board. If the supervisor cannot be easily contacted or if their details are incomplete, it could raise red flags, further complicating your application.

Moreover, keep an eye out for the supporting documentation. Applicants tend to overlook the requirement to attach payroll records or a detailed list of shifts and days worked. Failing to include this crucial information can lead to significant delays. Remember, every supporting document can help provide context and prove the validity of your statements, adding credibility to your application.

Another area where errors occur is in understanding the deadline for returning the attestation. A typical pitfall is missing the 5-business-day window following the submission of the renewal application. In a fast-paced world, it’s easy to misplace such deadlines, but falling short can lead to disciplinary actions. Keeping a calendar reminder can help you stay on track.

Lastly, misrepresentation on your attestation can lead to grave consequences. Many individuals fail to realize the depth of this issue if the information presented is not accurate. Misstating facts, even unintentionally, doesn't just delay the renewal process; it can also jeopardize your professional reputation. Always double-check every detail before submitting your form.

Taking the time to carefully review these potential pitfalls will help ensure a smoother process with the New Mexico Board of Nursing. Attention to detail not only reflects well on you but also sets the stage for a successful renewal journey.

Documents used along the form

When dealing with the New Mexico Board of Nursing form regarding an expired or lapsed license, there are several other documents that may be necessary. These documents help to provide additional information and support related to the renewal process and the circumstances surrounding the expiration or lapse of your nursing license. Below is a brief description of these commonly utilized forms.

  • Renewal Application Form: This is the primary document required for those seeking to renew their nursing license in New Mexico. It includes personal information, details about your nursing practice, and affirms your understanding of the professional standards expected of licensed nurses.
  • Verification of Employment: Often required to accompany the attestation form, this document confirms your employment history since your license expired. It typically includes the names of supervisors, contact information, and details about your work hours and roles.
  • Continuing Education Certificates: Nurses in New Mexico must often provide proof of continuing education. These certificates demonstrate compliance with educational requirements and are necessary for renewing your license.
  • Character References: In some cases, you may need to submit character references. These letters can help establish your professional integrity and may come from colleagues, supervisors, or other professionals attesting to your skills and character.
  • Affidavit of Good Moral Character: This may be required to assert that you possess good moral character and are fit to practice nursing. This affidavit includes personal declarations and, at times, may need to be notarized.

Make sure to gather and complete these documents thoroughly, as they play an essential role in ensuring a smooth renewal process. You must adhere to the timelines set by the New Mexico Board of Nursing to avoid any potential disciplinary actions that may arise from delays or incomplete submissions. Prioritize this process to maintain your good standing as a licensed nurse.

Similar forms

  • Affidavit of Compliance: This document requires individuals to confirm their adherence to specific laws and regulations. Similar to the New Mexico Board of Nursing form, it seeks sworn statements about professional conduct and compliance with licensing requirements.
  • Declaration of Professional Experience: Like the attestation form, this declaration requires a written account of professional work experience during a specified period. Both documents demand accuracy in reporting relevant work activity and a signature affirming the truth of the information provided.
  • Renewal Application for Licensure: When applying for renewal of a professional license, individuals must often affirm that they meet all educational and work experience requirements. This aligns with the New Mexico Board of Nursing form, which also asks for a statement regarding licensure status and justification for any lapse.
  • Verification of Employment: This document serves to confirm an applicant's employment history and professional experience. The requirement for supervisor names and contact information in both forms showcases the need for verifiable work details during the renewal or attestation process.
  • Statement of Continued Competence: This statement requires professionals to affirm their ongoing competence in their field. It operates similarly to the board of nursing form by ensuring that the individual is aware of their scope of practice and compliance with necessary standards during their licensing period.

Dos and Don'ts

When filling out the New Mexico Board of Nursing form, keep these important do's and don'ts in mind.

  • Do read the entire form carefully before starting.
  • Do ensure that all personal information is accurate and clearly printed.
  • Do provide a detailed explanation for the lapse in your license.
  • Do choose either question A or B, but do not attempt to answer both.
  • Do gather required documents, such as payroll records, before submitting the form.
  • Don't leave any sections blank; fill out all required fields.
  • Don't forget to sign and date the form at the end.
  • Don't provide false information; honesty is crucial.
  • Don't wait until the last minute to submit; allow time for processing.
  • Don't overlook the deadline to submit your attestation to avoid penalties.

Misconceptions

People often have misunderstandings about the New Mexico Board of Nursing attestation form. Here are four common misconceptions:

  • Misconception 1: You don’t need to submit any documents if your license has expired.
  • Many believe that simply completing the form is enough. However, if you have worked with an expired license, you must provide supporting documentation, such as payroll records. Failing to do so could lead to complications.

  • Misconception 2: The attestation process is optional.
  • Some individuals think that the attestation is merely a suggestion. In reality, returning this form and any related documents is mandatory. Missing the submission deadline can result in disciplinary actions affecting your license.

  • Misconception 3: You can submit the form any time after your renewal application.
  • It is a common belief that you can take your time with the attestation. However, the form must be submitted within 5 business days of your renewal application. Delays in submission can have serious repercussions.

  • Misconception 4: Misrepresentations on the form won’t have serious consequences.
  • Some people feel that minor inaccuracies might not be a big deal. This is a risky assumption. Any misrepresentation, even if unintentional, can lead to disciplinary action and be forwarded for investigation. It's essential to be truthful and thorough when filling out this form.

Key takeaways

Filling out the New Mexico Board of Nursing form accurately is crucial for maintaining your nursing license or certification. Below are key takeaways to consider when completing and submitting this form:

  • Be Honest: Ensure all information is accurate. Misrepresentation may lead to disciplinary action.
  • Understand Expiration: Know that allowing your license to expire can impact your ability to work in New Mexico.
  • Document Your Reason: Provide a clear explanation for why your license has lapsed or expired, as this will be part of your formal declaration.
  • Indicate Employment Status: You must choose whether you have worked on an expired license or not, and initial accordingly.
  • Provide Supervisor Details: If you've worked while your license was expired, include your supervisor's name, contact information, and your work history.
  • Submit on Time: Remember to return the attestation and any supporting documents within five business days of submitting your renewal application.
  • Attach Supporting Documents: If necessary, include additional documentation that supports your case, especially if you've worked while lapsed.
  • Initial Each Section: Carefully initial each statement where required to indicate your understanding and agreement to the content of the form.

By following these guidelines, you can help ensure a smoother process when dealing with your nursing license in New Mexico.

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