Name Change Request
If your legal name has changed, submit a name change request through MELS (Medical Enforcement & Licensure System). The change does not take effect until all required documentation has been notarized and mailed to the Mississippi State Board of Medical Licensure.
How to Request a Name Change
- Log in to MELS and open Request to Change Name.
- Enter your new name and upload your electronic photograph.
- Pay the fee for your license type (see the Fees table below).
- Mail the original notarized evidence of your legal name change to the Board at the address below.
Mail original notarized documents to:
Mississippi State Board of Medical Licensure
805 S. Wheatley Street, Suite 600
Ridgeland, MS 39157
Required Documents
You must supply the following:
- Electronic photograph. Follow the Photograph Guidelines below.
- Evidence of legal name change. This must be a notarized copy, mailed to the Board. Documents that show a legal name change include a marriage license, a final divorce decree, or a court order of name change.
- If your gender has changed, evidence of that change.
Fees
The fee depends on your license type and is paid in MELS when you submit the request.
| License Type | Fee |
|---|---|
| Doctor Permanent, Administrative, Physician Assistant, Radiologist Assistant, Acupuncture | $100.00 |
| Restricted Temporary, Limited Institutional | $20.00 |
| Limited X-Ray Machine Operator | $10.00 |
| Volunteer, Youth Camp, Short-Term Training, Out-of-State Training | No Fee |