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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  • 13 check-boxes
  • 31 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 5 helpdesk 1-231-873-4366
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 legal 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)
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. 08-1-2019
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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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