This form is to be used for a change of address only and should come from the licensee. If you wish to inform us of a name change, you will need to do so in writing with a notarized copy of the legal documents changing the name. Our address is:

Iowa Board of Medicine
400 SW 8th Street, Suite C
Des Moines, IA 50309-4686

It is important that the Board office maintains accurate contact information concerning all licensees in order to ensure that renewal notices and other important correspondence is sent to an appropriate address.

If you need a new renewal card with your updated address, you will need to submit a request for a duplicate renewal card, along with a $25 fee.

Board rules also require all licensees to inform the Board of any address change within thirty (30) days.

If your home or employment address has changed, please complete and submit the following information.

Name (First, Middle, Last):*
License Number:*
Date of Birth:*
Email Address:	Email is needed if you wish us to reply to this form.
Old Address: *
New Home Address Check here if no change is to be made to home address.
Address 1:
Address 2:
City, State, Zip:
County (Iowa):
Phone:
New Work Address Check here if no change is to be made to work address.
Address 1:
Address 2:
City, State, Zip:
County (Iowa):
Phone:
Please select a mailing/website address. This address will be used for correspondence sent by this office. This address will be displayed on our website with your license information. * Work Home Comments: *Check this box if you are ready to submit your change of address. Then click the submit button below.

Address Change