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:
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.- Contact information- REQUIRED- (Parent/guardian for minors):
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.