Michigan Care Improvement Registry (MCIR)
Patient/Parent/Legal Guardian Request to Change Information
NOTE: this form is ONLY for use by Patients, or the Parent/Legal Guardian of a Patient.
Medical Providers: You must NOT use this form to request a change in a patient’s record. Go to
then click on the applicable Region for your
office and use the forms provided.
Schools/Child Cares: The request MUST be from the parent/legal guardian if it is a legal name change. To eradicate
spelling errors schools/childcares may submit this form:
Complete ALL boxes in Part 1 exactly as the information currently appears in MCIR?
Print/type the NEW name in the appropriate field?
Include documentation showing the new name? Please indicate type:
State-issued ID or Driver’s License
Other Legal Document ___________________________________________________
Submit a copy of your picture ID or legal documentation showing your authority to make this request
as a parent or guardian?
Failure to submit a copy of one of the above acceptable documents will delay the processing of this request.
Fax or mail to your Regional MCIR Office:
PART 1: Record Information – Please print or type
Name as it currently appears in MCIR: All boxes with * MUST be completed. Put n/a if none.
*Date of Birth (mm/dd/yyyy)
PART 2: New Information: Fill in information as it should appear.
Correct Date of Birth (mm/dd/yyyy)
*Daytime Phone # w/Area Code
Requestor’s Name Please print or type
Relationship to person on record
Requestor’s Signature (This form MUST be signed.)
This document is subject to revision or withdrawal at the discretion of the Michigan Department of Health and Human Services. 2-17