In the dynamic world of professional health services, keeping one's contact information up to date is crucial for compliance and professional communication. The State of California, under the guidance of Governor Edmund G. Brown Jr., offers behavioral health professionals a seamless way to update their address information through the Board of Behavioral Sciences' BBS Address Change form. Located at their Sacramento office, the Board ensures a streamlined process for various licensed professionals, including Associate Clinical Social Workers, Marriage and Family Therapist Interns, and Professional Clinical Counselor Interns, among others. The form not only facilitates a change of address but also enables licensed individuals to request replacement licenses or registrations reflective of their new contact information. Clearly emphasizing the importance of accurate record-keeping, the form requires detailed information such as legal name, new address details, and social security numbers for certain providers. It also outlines the procedural steps for those in the examination process or those needing replacement documents due to loss or damage. The provided instructions and the mentioned fee for replacing documents underscore the Board's commitment to maintaining up-to-date licensure and registration information, which is publicly accessible as per the Business and Professions Code Section 27. This initiative highlights the importance of accuracy and transparency in the healthcare sector, ensuring that professionals' contact information is readily available for verification and outreach purposes.
| Question | Answer |
|---|---|
| Form Name | Bbs Address Change Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | bbs form request, bbs replacement license, bbs change, ca bbs address |
STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY |
Governor Edmund G. Brown Jr. |
BOARD OF BEHAVIORAL SCIENCES
1625 North Market Blvd., Suite S200, Sacramento, CA 95834
Telephone: (916)
www.bbs.ca.gov
REQUEST FOR ADDRESS CHANGE
REQUEST FOR REPLACEMENT LICENSE OR REGISTRATION
Check all licenses or registrations applicable to this CHANGE OF ADDRESS Request. Enter license or registration number and expiration date.
Associate Clinical Social Worker
Marriage and Family Therapist Intern
Professional Clinical Counselor Intern
Licensed Clinical Social Worker
Licensed Marriage and Family Therapist
Licensed Educational Psychologist
Licensed Professional Clinical Counselor
Continuing Education Provider
(Please type or print legibly in ink.)
ASW # |
___________ |
Expiration Date: ___________ |
IMF # |
___________ |
Expiration Date: ___________ |
PCI # |
___________ |
Expiration Date: ___________ |
LCS # |
___________ |
Expiration Date: ___________ |
MFC # |
___________ |
Expiration Date: ___________ |
LEP # |
___________ |
Expiration Date: ___________ |
LPC # |
___________ |
Expiration Date: ___________ |
PCE # |
___________ |
Expiration Date: ___________ |
Legal Name* (as it appears on your license or registration): |
Last |
First |
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Middle |
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NEW Address of Record**: |
Number and Street |
City |
State |
Zip Code |
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Social Security Number (Not required for CE Providers): |
Residence or Business Phone Number: |
Email Address: |
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Are you currently in the examination process?
Yes
No
Request for Replacement License/Registration
You may request a replacement license/registration, which will reflect your new address, by completing the section below and returning it with the required document and fee.
Check type of document being requested:
Engraved license certificate (8 ½ x 11)
Original or renewal license/registration (8 ½ x 3 5/8)
For Office Use Only
Cashiering No.
Date ordered: ___________ by: ____________
Submit a $20 fee for each replacement document requested
Document to be replaced must be returned with this application or you must state the circumstances regarding the loss of the
document here (please print clearly):
I hereby certify under penalty of perjury under the laws of the State of California that the foregoing are true and correct.
Signature of Licensee/Registrant |
Date |
*Business and Professions Code Sections 4982(b), 4992.3(b), 4989.54(b), and 4999.90(b) give the Board the right to refuse to issue any registration or license, or may suspend or revoke the license or registration of any registrant or licensee if the applicant secures the license or registration by fraud, deceit, or misrepresentation on any application for licensure or registration submitted to the Board.
**The address you enter on this application is public information and will be placed on the Internet pursuant to Business and Professions Code Section 27. If you do not want your home or work address available to the public, please provide an alternate mailing address.
FOR OFFICE USE ONLY |
Date changed: |
By: |
ATS: |
CAS: