Petition for Modification Form - Person Information
Please fax completed forms to the MCIR Region 4 Helpdesk 1-810-257-3809
This form is for provider use only. The public may use the Public Name Change Request Form available on MCIR.org.
To Change Person’s Date of Birth or Legal Name:
1) Verify the correct date of birth and/or legal name for the person with the legal documentation presented to
your office by the person or parent/guardian. Retain legal documentation for your records.
2) Print or type the correct date of birth and/or legal name on the Petition form in the box(es) provided.
3) Fax or mail only this form. DO NOT SEND LEGAL DOCUMENTATION.
Duplicate Records If you find that a person has more than one MCIR record, submit the information as follows:
1) Complete the “Person Information” section as required.
2) Indicate the duplicate information and duplicate MCIR ID number in the box(es) provided.
3) If the p
erson’s legal name has changed, be sure to include that information in the area provided.
sections 1- 4 MUST be completed. Failure to do so will delay the processing of this request.
SECTION 1 – Requestor’s Information (Please Print or Type)
Name of Practice (as entered in MCIR)
OR Site ID Number (Click here to locate number)
County Practice is Located In:
Person Completing This Form
SECTION 2 – Check the appropriate information below (do NOT include documentation):
2a. – Type of Change Requested:
2b. – Documentation Verified (Select
All that Apply):
Correct Date of Birth
Legal Name Change (MUST indicate type)
Elective (parental or person choice)
Driver’s License or State ID
2c.- Responsible party contact information (required):
SECTION 3 – Person Information (as it currently appears in MCIR – please print):
3a. – Name (Last, First, Middle, etc.)
Indicate the CORRECT information below – please print:
3b. – Name (Last, First, Middle, etc.)
If a person has two or more records please list the duplicate(s) below:
3c. – Name (Last, First, Middle, Suffix, etc.)
SECTION 4 – Signature REQUIRED
By signing below, I verify that I have retained legal documentation to support the changes requested above.