Form Ph-3619 Health Related Boards Name And Address Change Request Page 2

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665 Mainstream Drive
TENNESSEE DEPARTMENT OF HEALTH
Nashville, TN 37243
HEALTH RELATED BOARDS
615-532-3202 (Local) or 1-800-778-4123 (Toll Free)
NAME & ADDRESS CHANGE REQUEST
Select the profession/occupation for which you hold a license, certificate, or registration. NOTE: Submit a separate form for each license, certificate
or registration that you hold.
 Acupuncture
 Dispensing Optician-Apprentice
 Orthotist
 ADS
 Electrologist
 Osteopathic Physician
 Advanced Practice Nurse
 Electrology School
 Pedorthist
 Advanced Practice Social Worker
 Genetic Counselors
 Pharmacist
 Alcohol & Drug Abuse Counselor
 Hearing Aid Specialist
 Pharmacy Technician
 Athletic Trainer
 Hearing Aid Specialist-Apprentice
 Physical Therapist
 Audiologist
 Licensed Clinical Social Worker
 Physical Therapist Assistant
 Baccalaureate Social Worker
 Licensed Marital & Family Therapist
 Physician Assistant
 Certified Animal Chemical Capture Technician
 Licensed Masters Social Worker
 Podiatrist
 Certified Animal Euthanasia Technician
 Licensed Practical Nurse
 Podiatric X-Ray Operator
 Certified Martial & Family Therapist
 Licensed Professional Counselor
 Polysomnography
 Certified Nurse Aide
 Licensed Certified Respiratory Therapist
 Prosthetist
 Certified Professional Counselor
 Licensed Registered Respiratory Therapist
 Psychological Assistant
 Certified Respiratory Care Assistant
 Massage Therapist
 Psychological Examiners
 Chiropractic Physician
 Medical Doctor
 Psychologist
 Chiropractic Therapy Assistant
 Medical X-Ray Operator
 Radiology Assistants
 Chiropractic X-Ray Technologist
 Medical Laboratory Personnel
 Reflexologist
 Clinical Perfusionist
 Medical Service Representative
 Registered Nurse
 Clinical Pastoral Therapist
 Midwifery
 Speech Language Pathologist
 Dental Assistant
 Nursing Home Administrator
 Speech Pathologist Assistant
 Dental Hygienist
 Occupational Therapist
 Veterinarian
 Dentist
 Occupational Therapy Assistant
 Veterinary Medical Technician
 Dietitian/Nutritionists
 Optometrist
 Other (specify)________________________
 Dispensing Optician
 Orthopedic Physicians Assistant
SSN: _________________________
License, Certificate or Registration Number: ______________________
[PRINT OR TYPE ALL INFORMATION]
NAME CHANGE - T.C.A. § 63-1-106 - Personal name change requests must be accompanied by a copy of the legal document which verifies
the name change (marriage license, divorce decree, court order).
New Name: [First] ____________________________
[Middle] ________________________
[Last] ________________________
Former Name: [First] ___________________________
[Middle] ________________________
[Last] ________________________
MAILING ADDRESS CHANGE - T.C.A. § 63-1-108(c) – THIS WILL BE USED AS YOUR MAILING ADDRESS FOR THE PURPOSE OF BOARD
MAILINGS. BOARD RECORDS ARE PUBLIC RECORD PURSUANT TO T.C.A. § 10-7-503.
Old Street Address: __________________________________________________ City, State, Zip Code: ____________________________________
New Street Address: _________________________________________________ City, State, Zip Code: ____________________________________
PRACTICE ADDRESS CHANGE – This will be also be used for the purpose of your practitioner profile if you are required to provide a profile.
Old Street Address: __________________________________________________ City, State, Zip Code: ____________________________________
New Street Address: _________________________________________________ City, State, Zip Code: ____________________________________
TELEPHONE NUMBER CHANGES:
Home __________________________________
Work __________________________________
EMAIL ADDRESS CHANGE:
_________________________________________________________________________________________
_____________________________________________________________________
____________________________________
Signature
Date
Print Name: ___________________________________________________________
PH-3619
RDA-1786
Rev. 1/09

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