NYC Birth Certificate Correction Checklist

Transcription

1 NYC Birth Certificate Correction Checklist To change the name & gender on a birth certificate issued by New York City, assemble the following. Corrections take 6-8 weeks. * One certified copy of the name change order. It will be returned to you. * One photocopy of the name change order. DO NOT REMOVE ANY RECEIPT OR STAPLES when copying the order. Alternatively, you can print out a scan of the final order. transcendlegal.org nd St. #6D Jackson Heights, NY (347) office (347) fax * One original letter from an MD or DO. (Non-physicians may also provide a letter, see the sample form.) It will be returned to you. * One photocopy of the health care provider letter. * Birth Certificate Correction Application (NYC Form VR-172). o In Section 1, fill in your name (or the parent s name if the person is under 18). In Section 2, put the old name & sex. o o In Section 3, under items to be corrected list child s sex and then male/female as appropriate. List separate lines for each name that you are correcting, for example child s first name child s middle name and fill in the information accordingly. Leave Section 4 blank. Sign in Section 5 on the second page (or if under 18, both parents listed on the birth certificate must sign) * A photocopy of the front & back of your current, signed photo identification, or if under 18, for both parents who signed. * A check or money order for $55 made out to the NYC Dep t of Health and Mental Hygiene ($40 processing fee + $15 for a copy). Order only one corrected copy with this application and order more later if desired. * A self-addressed, stamped envelope. Mail your documents to: NYC Department of Health and Mental Hygiene Corrections Unit 125 Worth Street, Room 144, CN-4 New York, NY Questions? tgnyc@health.nyc.gov or call 311.

2 Sample Doctor's Letter for Sex Designation Changes This letter meets federal requirements to change the sex designation with Social Security, on a passport, or on immigration documents. It can also be used to change the sex designation with the NY DMV and on New York City (but not New York State) birth certificates. It does not need to be notarized. Sample letter meeting federal government requirements: transcendlegal.org nd St. #6D Jackson Heights, NY (347) office (347) fax I, [Physician s Full Name], am the physician of [Preferred Name of patient a/k/a Current legal name], DOB: [ of Birth], with whom I have a doctor/patient relationship and whom I have treated [or with whom I have a doctor/patient relationship and whose medical history I have reviewed and evaluated]. [Preferred Name of Patient] has had appropriate clinical treatment for gender transition to the new gender of [specify male or female]. I declare under penalty of perjury under the laws of the United States that the forgoing is true and correct. Signature of Physician Typed Name of Physician [issuing U.S. State/Foreign Country of medical license/certificate & physician s medical license or certificate number] Requirements for this letter: q Printed on letterhead that includes: o Physician s address o Telephone number q Signed by an MD or DO q Provide three original copies to the patient. o Photocopies and scans are not acceptable. o Ideally, sign in blue ink.

3 NYC Birth Certificate Correction: Provider Instructions ü Only use this form if the provider is not a physician. Physicians can simply use the standard federal gender marker change letter and don t need to fill out this form; ü If you are not a physician, you must have this form notarized; transcendlegal.org nd St. #6D Jackson Heights, NY (347) office (347) fax ü On the form below, use the patient s name as it appears on their birth certificate; ü Fill in all blank lines; ü Give the original, signed form to the patient. Electronic copies are not accepted. Questions? info@transcendlegal.org or call (347)

4 Provider s letterhead OR Provider s address: Provider s phone: Provider s Patient s/client s Full Name: Patient s/client s of Birth: Patient s/client s Address: I,, am a U.S.-licensed healthcare provider in good standing: (Provider s full name) Please check one box: Physician (MD or DO) Doctoral-level psychologist (PhD or PsyD in clinical or counseling)* Social worker (LMSW or LCSW)* Physician assistant* Nurse practitioner* Marriage and family therapist* Mental health counselor* Midwife* Note: Notarization of this letter is required for providers with an asterisk (*). I am the healthcare provider of, whom I have treated (or whose history I have (Name of patient/client) reviewed and evaluated). I hereby certify and confirm that, in keeping with contemporary expert standards regarding gender identity, s requested change of sex designation from to accurately (Name of patient/client) (M/F) (M/F) reflects their gender identity. I declare under penalty of perjury under the laws of the United States that the forgoing is true and correct. Signature of Provider: Typed or Printed Name of Provider: : License Number: State Issued: License Type: NPI Number: Provide notary s signature and legal information in box below: January 14, 2015

5 VR 172 (Rev. 01/15) DEPARTMENT OF HEALTH AND MENTAL HYGIENE OFFICE OF VITAL RECORDS Reference No. Birth Certificate Correction Application Form Please use blue or black ink ONLY. Section 1: What Is Your Name? You Must Be At Least 18 Years Old First Name Middle Name Last Name Mailing Address Apartment Number City State ZIP Code Telephone Number Wireless Carrier Home Area Code Cell Area Code Daytime Area Code Telephone Number Telephone Number AT & T T-Mobile Sprint Verizon Other Telephone Number Address Marital Partnership Status Single Married Separated Divorced Widowed Domestic Partnership Section 2: Birth Certificate Information Birth Certificate Number Name on Birth Certificate as it now appears First Name Middle Name Last Name Sex Male Female Place of Birth of Birth / / Month Day Year Mother s Maiden Name First Last Name of Hospital, birthing center or if born at home, street address, city, state, ZIP) Section 3: What Do You Want To Correct? Please use one line per correction. We cannot accept white-outs or cross-outs; if you make a mistake, please use a new application form. List items to be corrected Example: Child s First Name Example: of Birth Write errors as they appear on birth record Not Shown October 16, 2009 What should it say on birth record? Michael October 19,

6 Section 4: Second Parent Information If you want to add the name of another parent, please fill out this section. You must have been married prior to the birth of the child. See How Do I Add the Name of Another Parent? on page 2. Name of Second Parent First Name Middle Name Last Name of Second Parent Sex Male Female / / Second Parent s of Birth Month Day Year Parent s Country of Birth Second Parent s Age at Time of Child s Birth Child s Last Name (as it will appear on the certificate even if it will remain the same) Signature of Second Parent Section 5: Sign Your Application Please sign the form where appropriate. If both parents names appear on the birth certificate, both must sign if the child is under 18. Signature of Mother/Parent/Legal Guardian Signature of Father/Parent/Legal Guardian Your Signature (if you are 18 or older and are requesting a correction of your own birth certificate) Signature of Self Warning! No person shall make a false, untrue or misleading statement or forge the signature of another on an application required to be prepared pursuant to the New York City Health Code. A violation of the Health Code shall be punishable as a misdemeanor. (NYC HEALTH CODE 3.19) How to Submit Your Application: A copy of the corrected certificate costs $15. This fee is waived if you enclose a certified copy of a certificate purchased within the past 3 months and want to exchange it for a corrected certificate. Figure out the cost: Processing Fee: $40 (See page 1 for applicable fees. $ ( not all corrections have a fee.) Copy Fee: number of copies X $15 each $ Total Amount Enclosed: $ Please make your check or money order payable to the: New York City Department of Health and Mental Hygiene. Cash not accepted. Walk-in customers may pay using a credit or debit card. Make certain you have enclosed everything necessary (please check all that apply): Completed, signed application with a copy of photo One photocopy of each original or certified copy identification for each parent named on birth record Payment if applicable Original or certified documents If mailing, self-addressed, stamped envelope. Submitting false identification is a crime and violators are subject to prosecution. MAIL TO: NYC Department of Health and Mental Hygiene Corrections Unit 125 Worth Street, Room 144, CN-4 New York, NY FOR HEALTH DEPARTMENT USE ONLY Certification by the NYC Department of Health and Mental Hygiene This is to certify that I have examined the original record that this application seeks to correct, and any original documents required to verify the correction. There are no omissions or apparent errors in the original record that have not been covered. Therefore, the application is approved. Signature of Deputy City Registrar DOCUMENT NO. VR 172 (Rev. 01/15) - 4 -