On-Line Change-of-Address Form

	State Medical Board of Ohio On-Line Change-of-Address Form
	Every licensee of the Medical Board is required by statute to have on file with the Board their residence address and their principle practice address, if they have one. Each licensee is further required to report any change of either address to the Board within 30 days of the change. Please use this form to notify the Medical Board of any address change. Fill out the entire form below. When you have finished, please click the Submit button to send your information to our Records Department.
Today's Date:
Your Name:		License Number:
Effective Date of Address Change:
Email address:	(Optional)
	New Residence Address
Address Line 1:
Address Line 2:
City:
State:		Zip Code:
Phone Number	(Optional)
	New Principal Practice Address
Address Line 1
Address Line 2
City:
State:		Zip Code:
Phone Number:	(Optional)
	Select One Address for Mailings from the Board Residence Address Principal Practice Address