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State Board of Medical Examiners
Address Change Form for Physicians, Podiatrists and Lab Directors

N.J.A.C. 13:45C-1.3(a)7 requires that all New Jersey licensees provide a timely notice of any change of address from that which appears on the licensee's most recent license renewal or application.

If your MAILING ADDRESS is not current, you will not receive your license renewal form or any other Board mailings. To ensure that you will receive all Board mailings, you must immediately send the Board your current address information.

Be advised that your New Jersey licensing board/committee retains your: Home Address, Business Address and Mailing Address. One of these you determine to be your address of record. Your address of record is the address that will be printed on your renewed license certificate. Your name and this address may also be posted as part of the Online Licensee Directories at: http://www.state.nj.us/lps/ca/director.htm . As a matter of information, under the public disclosure law as it currently stands, any of your license addresses (address of record, home, business and mailing) must be provided if requested under the Open Public Records Act. If you do not indicate an address of record, your mailing address will be considered your address of record. An address of record may be a post office box address only if another address with a street address is provided.

This change of address form may be completed and submitted electronically by clicking the "Submit the Form" button below to meet the address reporting requirement. This form is for address change reporting only. If a duplicate license certificate with the new address is required, please mail a certified check or money order for $50.00 payable to the New Jersey State Board of Medical Examiners. Send to

New Jersey State Board of Medical Examiners
Licensee Service Center
PO Box 183
Trenton, NJ 08625-0150
. Print your license number on the certified check or money order.

RENEWAL APPLICATIONS ARE NOT FORWARDED
BY THE POSTAL SERVICE TO A FORWARDING ADDRESS.

(Indicates required fields)

Last Name:   (as it appears on your license certificate)
First Name:   (as it appears on your license certificate)
Two-letter Alpha Code:   (Precedes five-digit license number)
Five-Digit License Number:  
Date of Birth:     (Use MM-DD-YY format.)
The date of birth will be used for verification purposes only.
Daytime Telephone Number:    (Use 555-555-5555 format.)
The telephone will be used in the event that questions arise concerning this change of address form.
E-mail address: 


Old

 Mailing Address
Business Address
Home Address

Street:
City:
State:
ZIP Code:
Country:  (if not U.S.A.)

New mailing address
If this new mailing address is your address of record, please click here?

Business or Practice Name:
(if applicable)
Street:
City:
State:
ZIP Code:
Country:  (if not U.S.A.)

Note: If your mailing address is a business or practice location, you must provide the business or practice name in order to ensure mail delivery.

New business address
If this new business address is your address of record, please check the box?

Business or Practice Name:
(if applicable):
Street:
City:
State:
ZIP Code:
Country:  (if not U.S.A.)

New home address
If this new home address is your address of record, please check the box?

Street:
City:
State:
ZIP Code:
Country:  (if not U.S.A.)

Name Changes: Mail a copy of your marriage certificate, divorce decree or court order, your engrossed wall certificate (license) and your original certificate of registration (these documents will be reissued to you with your new name) to: New Jersey State Board of Medical Examiners, Licensee Service Center, PO Box 150, Trenton, NJ 08625-0150. Print your former name, complete license number (include the two letter prefix), and daytime telephone number on the copy of your name change documentation. If a duplicate license certificate is required, please mail a certified check or money order for $50.00, payable to the New Jersey State Board of Medical Examiners. Print your license number on the certified check or money order.

           


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