Privacy Information Act

(PIA) Request Form



When you applied for a license to practice audiology, hearing dispensing, speech-language pathology or music therapy, the application included your official mailing address to be used by the Board to send all mail.



Under the Public Information Act the public is granted access, or can be denied access, to records. This notice is to inform you that your name and address is on a mailing roster and is available to the public for purchase.



Please complete the form and return it to the Board.


If you do not return this form, you are giving the Board permission to keep your name and mailing address on the roster.


PIA Request Form

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Scan and upload a signed and completed request form


Please use the link below to print and sign the PIA request form.


PIA Form

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