ADDRESS CHANGE FORM

You must inform the Board of any change in your office or home address within 30 days of the change as required by Board Rule 4734-6-07. You are prohibited from filing a post office box address without also disclosing the actual physical location of the address you are reporting.

All licensees must file with the Board the business name and address of all facilities that provide or administrate health related services in which they are employed, own, operate, manage or otherwise have any ownership or fiduciary interest within the state of Ohio.

Upon receipt of an Address Change Form the Board will change its records for your primary practice location unless otherwise stated on the form.  If you are reporting a change of information for a location other than your primary practice location, please clearly indicate this in the comments section.

 

Your Name: *
Home Address: *
Home Phone: *
Is this number unlisted: *
License Number: *
Office Name: *
Office Address: *
City: *
County: *
State/Province: *
Zip/Postal Code: *
Country: *
Phone Number: *
Fax Number: *
Email Address: *
Web Page Adddress:
Effective Date: *
Comments:
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CONTACT

Kelly Caudill, Executive Director
77 South High Street, 16th Floor
Columbus, OH 43215
614-644-7032 | 888-772-1384
Fax 614-752-2539