AMA Secure data change form

US physicians and students attending US-accredited medical schools can use this form to send address or other data changes.

For validation purposes, please provide the following information:

Category

*
Denotes a required field
Are you a:
*
Physician
Resident
Student

AMA Secure data change form

Contact Information

*
Denotes a required field
First Name
*
Middle Initial
 
Last Name
*
Date of Birth
*
(MM/DD/YYYY)
Year of graduation
*
(YYYY) Year of graduation or expected year of graduation from medical school.
Email
*

AMA Secure data change form

Mailing Address Change/Verification

*
Denotes a required field

If making a mailing address change, please enter your new address, otherwise enter your current address. Note that address changes will redirect all of your professional mail (including journals) to the new address. Please allow 3-6 weeks for all affected mail to be corrected.

Is this address your home or office?
 
 
 
Home
Office
Address
*
Address Line 2
 
City
*
State/Territory
*
ZIP Code
*
Phone number
 
Home
Office
Phone
 
000-000-0000
Effective date of new address
 
(MM/DD/YYYY)

AMA Secure data change form

Other data changes

*
Denotes a required field
Please submit other data changes below (e.g. specialty, office address, residency training, board certification, additional contact information, etc.)