If you would like to request a change to a patients legal name, please fill out the form below. Contact Information First Name * Last Name * Phone * Email * Patient Name previous/misspelled (first name, last name) * Patient Name new/correct (first name, last name) * Patient Date of Birth (mm/dd/yyyy) * Comments Upload legal documentation * Files must be less than 2 MB.Allowed file types: gif jpg jpeg png pdf doc docx. Leave this field blank