Physician’s Statement in Support of Amendment of a Birth Certificate
Following Medical Intervention for the Purpose of Sex Reassignment
Registry of Vital Records and Statistics
Massachusetts Department of Public Health
Form
An individual born in Massachusetts may request an amendment to the sex on their Massachusetts birth
certificate following completion of medical intervention appropriate for that individual for the purpose of
permanent sex reassignment, as outlined by Massachusetts General Law Chapter 46, §13(e). This form serves
as the physician’s notarized statement to accompany an individual’s application to amend the sex on their
birth certificate.
Chapter 46, §13(e), M.G.L., states:
If a person has completed medical intervention for the purpose of permanent sex reassignment, the
birth record of that person shall be amended to permanently and accurately reflect the reassigned sex if the
following documents have been received by the state registrar or town clerk:
(i) an affidavit executed by the person to whom the record relates or by the parent or guardian if such person is a
minor indicating the individual's sex; and
(ii) a physician's notarized statement that the person has completed medical intervention, appropriate for that
individual, for the purpose of permanent sex reassignment and is not of the sex recorded on the record.
The affiant shall furnish a certified copy of the legal change of name if the affiant is seeking a birth record with
the legal change of name instead of the name as appearing on the birth record prior to the amendment.
Information to
Appear on Birth
Certificate
information
Name and Address of Practice or Clinic:
I am a licensed physician in good standing in the State or jurisdiction listed above. I am a physician of the
patient listed above, with whom I have a doctor-patient relationship and whose medical history I have
reviewed and evaluated. I make this affidavit in support of my patient’s request for a permanent amendment
of the birth certificate registered with the Massachusetts Registry of Vital Records and Statistics pursuant to
M.G.L. c.46 §13(e). I hereby certify that my patient, listed above, has completed medical intervention,
appropriate for the patient, for the purpose of permanent sex reassignment. In my medical opinion the
patient is not of the sex recorded at birth and the sex on their amended birth certificate should be listed as:
Male Female.
I declare under the pains and penalties of perjury that the information above is true and accurate.
On this_______ day of __________________, 20_____, before me, the undersigned notary public, personally
appeared __________________________________________________________, who proved to me through
satisfactory evidence of identification, which was or were __________________________________________,
to be the person who signed the preceding document in my presence, and who swore or affirmed to me that
the contents of this document are truthful and accurate to the best of (his) (her) knowledge and belief.
Notary Signature_____________________________________________________
