INDIVIDUAL NAME CHANGES
The individual name that appears on your license/registration must be your legal name. If it is not, you need to update your record by filling out a Name/Address Change Affidavit and submitting it with the proper documentation (i.e., a marriage license, divorce decree, or court document noting name change) to the Division.
Every record at the Board contains 2 addresses.
- Address of Record: This is the address that appears on your license/registration and is public record.
- Confidential Address: This address is not public record.
Licensees have the option of selecting either one as their mailing address.
Any change in your address of record or your mailing address can be reported to the Board by updating the information online or mailing a signed, written request. If you have moved or otherwise changed one or both of these addresses since your last license/registration was issued, you must notify the Board as soon as possible.
The Board also maintains business phone numbers and e-mail addresses for those that wish to provide them. The business phone number you provide will be part of your public record. The e-mail address you provide may be used by the Board to send correspondence to you. This e-mail address is not a public record. These may also be updated online.
There is no fee required to update any of the contact information in your Board record. If you wish to have a license re-printed to reflect the address changes you have made, a fee of $10.00 is required.
If you prefer to submit changes to your address offline, please mail a signed, written request to the Board of Medicine, PO Box 83720, Boise, ID 83720-0063.
PHONE NUMBER & E-MAIL ADDRESS
The Division also maintains business phone numbers and e-mail addresses for those who wish to provide them. The business phone number you provide will be part of your public record. The e-mail address you provide will be used by the Board and Division staff to send correspondence to you. Your e-mail address is not a public record.
There is no fee required to update any of the contact information in your division record.
** You will not receive a copy of your license/registration bearing the updated information until the next renewal period unless you submit the name change form along with the required documentation prior to renewing online.
- Application for Medical Resident/Intern
- Application for Physician and Surgeons
- Application Physician Re-entry After Absence from Practice
- BOM Request for Official Licensure Certification Form
- Criminal Conviction Disclosure Form
- Directing Physician Registration Form & AT Service Plan or Protocol Forms
- Duplicate License Application
- Inquiry on Impact of Conviction Form
- Medical Malpractice Prelitigation Claim Form
- Medical Personnel Supervising Physician Registration Form (including Cosmetic & Laser supervision)
- Name and Address Change Affidavit
LINKS and OTHER INFORMATION
Physicians and physician assistants may obtain primary source license verifications online through VeriDoc.
Request a Speaker
If you would like a member of the staff to speak to your organization or civic group please let us know. Include information on how we may contact you, the areas of interest and group/organization name. Click here to send us an email or call us at 208-327-7000.