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State Medical Board of Ohio



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name change affidavit

To obtain a duplicate wall certificate and duplicate wallet card printed with the new name you must complete the name change affidavit form before a Notary Public and return it to this office with a money order or check made payable to theOhio Treasurer, Josh Mandel for $70.00. THIS FEE IS NOT REFUNDABLE.

You must also submit your original wall certificate and wallet card directly to the Ohio Medical Board at 30 E. Broad Street, 3rd th Floor, Columbus, Ohio 43215-6127.

Include a certified copy of the name change document (i.e., marriage certificate, divorce decree, etc) to this office so we may change our records to reflect the name change.

Processing of a duplicate wall certificate takes approximately seven (7) to ten (10) days.

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30 East Broad Street, 3rd Floor, Columbus, Ohio 43215-6127 | Telephone: (614) 466-3934 | Fax: (614) 728-5946
Complaint Forms: (800) 554-7717 | Licensure Verification: (800) 357-7720