The Candidate Change Request Form is used to update exam and Prometric registry files for name and address changes, however, you may also request a duplicate certificate in states that Prometric manages the registry – currently AR, CT, HI, MI, ID, NM and NY. If your state is not listed, Prometric does not provide registry services and cannot supply a duplicate certificate. Fill out the form and mail the completed form to the address indicated.
Check the appropriate box indicating you are requesting a duplicate certificate. Be sure to include any documentation of changes required. There is a fee to receive a duplicate certificate. The NY fee, which is currently $15, may be paid only by certified check or money order made payable to: NY Commissioner of Health. Make sure to complete the payment information on the last page of the form.