Fillable Petition for Modification Form - Person Information (Michigan Care Improvement Registry)

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Petition for Modification Form - Person Information (Michigan Care Improvement Registry)

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The Petition for Modification Form - Person Information (Michigan Care Improvement Registry) form is 1 page long and contains:

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  • 21 check-boxes
  • 27 other fields

Country of origin: US
File type: PDF

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Petition for Modification Form - Person Information
Please fax completed forms to the MCIR Region 2 Helpdesk 1-269-373-5079
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 person’s l
egal name has changed, be sure to include that information in the area provided.
All
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:
Area Code + Phone Number
Person Completing This Form
Email Address
Area Code + Fax Number
SECTION 2 – Check the appropriate information below (do NOT include documentation):
2a. – Type of Change Requested:
2b. – Documentation Verified (Select
All that Apply):
Duplicate Record
Correct Date of Birth
Correct Gender
Correct Spelling
Legal Name Change (MUST indicate type)
Elective (parental or person choice)
Marriage/Divorce
Adoption
Birth Certificate
Legal/Court Papers
Adoption Papers
Passport
Driver’s License or State ID
Notes/Comments:
Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
SECTION 3 – Person Information (as it currently appears in MCIR – please print):
3a. – Name (Last, First, Middle, etc.)
Date of Birth
MCIR Person ID
Gender
M F
Indicate the CORRECT information below – please print:
3b. – Name (Last, First, Middle, etc.)
Date of Birth
MCIR Person ID
Gender
M F
If a person has two or more records please list the duplicate(s) below:
3c. – Name (Last, First, Middle, Suffix, etc.)
Date of Birth
MCIR Person ID
Gender
M F
M F
SECTION 4 – Signature REQUIRED
By signing below, I verify that I have retained legal documentation to support the changes requested above.
Signature: Date:
FOR MCIR USE
ONLY
Date Received:
Date Corrected:
Staff Initials:
Rev. 04-13-2017
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Petition for Modification Form - Person Information (Michigan Care Improvement Registry)

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Completed 3 June 2021

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