Information for requesting a Name Change

Name changes require legal documentation showing the name change. Please submit a request including your full name as it appears on your license, profession, license number, your new name, your date of birth, the last four digits of your social security number, and your signature. Attach supporting documents, which must be one of the following:

  • a copy of a state issued marriage license that includes the original signature and seal from the clerk of the court
  • a divorce decree showing the name change
  • a court order showing the name change (Adoption, legal name change, federal identity change)

Any one of these will be accepted unless the department has a question about the authenticity of the document. A social security card is not considered legal documentation.

Please Note: The last four digits of the SSN are requested as required by DOH Policy Number DOHP 385-LS05-12 Name Changes for Existing Licensees, which was established for security purposes due to past instances of fraudulent activity.

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Information for requesting a Name Change

Name changes require legal documentation showing the name change. Please submit a request including your full name as it appears on your license, profession, license number, your new name, your date of birth, the last four digits of your social security number, and your signature. Attach supporting documents, which must be one of the following:

  • a copy of a state issued marriage license that includes the original signature and seal from the clerk of the court
  • a divorce decree showing the name change
  • a court order showing the name change (Adoption, legal name change, federal identity change)

Any one of these will be accepted unless the department has a question about the authenticity of the document. A social security card is not considered legal documentation.

Please Note: The last four digits of the SSN are requested as required by DOH Policy Number DOHP 385-LS05-12 Name Changes for Existing Licensees, which was established for security purposes due to past instances of fraudulent activity.