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    Maryland Department of Health
    Board of Occupational Therapy Practice

    Name and Address Changes

    Statement of Privacy - Public Information

     

    Name Change

    An applicant or licensee shall report a change of name, in writing, within 30 days of the change.  Notification must include:

    • Notarized copy of legal document substantiating name change, such as marriage certificate or court order; and
    • Return of official license bearing former name; and,
    • Return of pocket license bearing former name.

    THERE IS NO FEE FOR A REPLACEMENT LICENSE DUE TO NAME CHANGE. 

    A Change of Information Request form can be downloaded by clicking here.

     

    Address Change

    An applicant or licensee shall report a change of address, in writing, within 30 days of the change.  The licensee may utilize the form listed below.  They will receive confirmation of receipt from the Board office within 30 days.  It is the responsibility of the licensee to follow up if confirmation is not received.  All correspondence, including renewal forms, will be sent to the last known address. 

    A Change of Information Request form can be downloaded by clicking here.

    Statement of Privacy

    This notice is given to comply with State Government Article §10-624 (as amended by Chapter 4, acts 2000, effective October 1, 2000):

    The information collected on the license application form and the license renewal form is collected for the purposes of the Board's function under the Maryland Health General Code Annotated Title 10.  Failure to provide the information may result in the denial of your application for an initial or renewed license.  You have a right to inspect, amend, and correct this information.  The Board may permit inspection of this information, or make it available to others, only as permitted by federal and State law.  The Board may sell or provide a list of licensees' names and addresses or professional associations and other entities.  Under the Maryland Public Information Act. Maryland State Government Code Annotated 10-617, you may request in writing that your name be omitted from such lists.

    Address changes can also be sent via email or fax.  Be sure to include your name, license number, address and phone number.  Our email address is mdotboard@dhmh.state.md.us.  Our fax number is 410-402-8561.

    Name changes can be sent via fax or U.S. mail.  Be sure to include a notarized copy of a legal document substantiating your name change.

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