Iowa Department of Public Health - Protecting and Improving the Health of Iowans

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Name Change Request Form

A licensee shall notify the board of a name change within 30 days of the change. Please keep in mind this is public information.

Complete and submit this form to request a name change for your license. You must include a picture of the legal document that changed your name. Examples of accepted documents are: a marriage certificate, court order, or dissolution of marriage decree.

Please note: A Driver's License is not an acceptable document for a proof of name change.

Request a name change before renewing. For a new wall certificate, go to https://amanda-portal.idph.state.ia.us/ibpl/portal/#/dashboards/index to request from the online services option and pay the $20 fee.

Note: This form should not be used to change the name or owner of an establisment.

Important: A name change request can take between 24-72 hours to complete. Please do not request documents from the office until the name change is complete.

Board:

License type:

Previous first name:

Previous middle name:

Previous last name:

Date of birth:

format required: mm/dd/yyyy

Current address line 1:

Current address line 2:

Current City:

Current State:

Current ZIP code:

Primary phone number:

Primary phone type:

Secondary phone number:

Secondary phone type:

Email:

New first name:

New middle name:

New last name:

Note: Document image 1 is required. Use document image 2 if necessary. Acceptable file types include: .jpg, .jpeg, .gif, .png, or .pdf

Document image 1:

Add File

Document 1 description:

Document image 2:

Add File

Document 2 description:

Checking this box affirms that the information I have provided in this request is true and accurate. I have truthfully represented my identity in this request for a name change in my licensure record.

Contact Information & Office Hours

Bureau of Professional Licensure
321 E. 12th St.
Des Moines, IA 50319

Phone: (515) 281-0254

Fax: (515) 281-3121

Bureau Website: https://idph.iowa.gov/licensure

Online Licensure Services: https://amanda-portal.idph.state.ia.us/ibpl/portal/

Email: PLPublic@idph.iowa.gov

Office Hours:

8:00 am to 4:30 pm
Monday through Friday, excluding state holidays

Name Change Request Form

Section I - Licensee Information

Section II - New Name Information & Documents

Section III - Licensee Affirmation

Contact Information & Office Hours