Hospital Statement to Correct or Amend a Birth Record
This form is to be used to request a correction or amendment to a birth record from the Office of Vital
Records. Requesters must complete the entire statement, including requester contact information and
signature.
Birth Record Information
Child’s full name
State File Number
Child’s date of birth
Mother’s name
Choose one:
☐correct birth record (can be done within one year of the child’s birth and before a certificate is issued – no fee)
☐amend birth record (must be done after a certificate is issued or more than one year after the child’s birth - $40 fee
required)
☐delete duplicate birth record
Identify the item(s) that need to be changed (from and to):
Requester Information
I have verified that the information provided here is accurate according to hospital records.
Requester Signature
Date
Name
Facility
Receipt Address – Street
City
Phone
Email
State
ZIP
Payment and Submission
☐Check
Name on card
Office of Vital Records:
☐Credit card
Card number
Fax: 651-201-5740
Expiration date
If paying by credit card:
3 digit security code
Email: [email protected]
Mail: Minnesota Department of Health – Central Cashiering – Vital Records, PO Box 64499, St. Paul MN 551640499
PENALTIES: Any person who willingly and knowingly supplies false information used in the preparation of an amendment is guilty of a
misdemeanor or gross misdemeanor (Minnesota Statutes, section 144.227).
REV 07/2013