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HEA0152 Source Address Request Change form

IMPORTANT: THIS FORM MUST BE DOWNLOADED TO A PC, COMPLETED AND E-MAILED OR FAXED AS AN ATTACHMENT. THIS FORM IS UNABLE TO BE SENT THROUGH AN INTERNET BROWSER AS THE SUBMIT BUTTON HAS BEEN REMOVED. ATTEMPTING TO DO SO COULD RESULT IN A LOSS OF TYPED INFORMATION.

Please click the "Download" button to view the Source Address Change form HEA0152.

 

 

Each address that possesses x-ray equipment (operable, inoperable or in-storage) must have a current, valid registration.

A new registration must be submitted for the new address if any x-ray equipment remains at the old address.

No x-ray equipment can remain at the old address (operable, inoperable or in-storage) without a current, valid registration.

You can also use this form to change your mailing and billing addresses at the same time.

Please send the completed form to our department via e-mail to xrayreg@odh.ohio.gov or fax to 614.644.8526