1. 1. The following information:

   1. a. The registered health care provider’s name, address, telephone number, and email address; and
   2. b. The new name, address, telephone number, or email address, if applicable;

2. 2. If the registered health care provider’s name has changed, a copy of one of the following with the registered health care provider’s new name:

   1. a. Marriage certificate,
   2. b. Divorce decree, or
   3. c. Other legal document establishing the registered health care provider’s new name.
3. 3. If the registered health care provider’s professional liability insurance policy has changed, a copy of the registered health care provider’s new professional liability insurance policy; and
4. 4. If the statutory agent has changed, the name, address, telephone number, e-mail address, and, if applicable, business name of the statutory agent.

Within 30 calendar days after the effective date of a change, a registered health care provider shall submit to the Department:

Historical Note

New Section made by final rulemaking at 30 A.A.R. 695 (April 5, 2024), effective May 13, 2024 (Supp. 24-1).