Birth Attendant Application and Change Request
This form is used to add, remove, and change birth attendant information in the
Minnesota Registration & Certification database system (MR&C). Only Minnesota
licensed physicians, residents and certified nurse midwives will be added.
☐Add
☐Change name only
☐Remove
Former Name:
☐Change address or primary clinic
Birth Attendant
License Number
First Name
NPI Number
Title
Phone
Middle Name
Last Name and Suffix
Address of primary clinic (for hospitalist, use hospital address) – Street
City
State
Zip
Requester
Facility Name
City
Requester Name
Date
Requester Signature
Phone Number
Fax completed form to Data Quality Unit, Office of Vital Records, 651-201-5750, or email to
[email protected].
If you have questions, please contact the MR&C Support Line at 651-201-5993 or 888-692-2733.
REV 08/2013