Complete and sign this form to request a name change or correction to name, date of birth, or sex. You must submit legal documentation (see page 2 of form) with this form for a change to be made to a patient's name. The patient (if over 18) or parent/legal guardian must sign this form before the name can be changed.
Mailing Address:
Attn: Medical Records (BCH3040)
300 Longwood Ave.
Boston, MA 02115
Fax: 617-730-4675
Phone: 617-355-6436