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2025 Neurology Medical Symposium

Patient Legal Name Change Request Form

At DENT Neurologic Institute, we respect all patients’ identities and are committed to addressing you correctly. If you have legally changed your name due to marriage, divorce, gender transition, or other reasons, please complete this form and provide the necessary documentation.

Please allow 7–10 business days for processing a legal name change. Note: Our records will be updated once the required documentation is received.

Please download and sign the HIPAA and Practice Policies forms using your new legal name. You will be asked to upload these documents at the end of the questionnaire.

HIPAA & Practice Policies Signed with New Legal Name

HIPAA Form
Patient Policies

Patient Legal Name Change Request Form

Please download and sign the HIPAA and Practice Policies forms using your new legal name. You will be asked to upload these documents at the end of the questionnaire. Additionally, please have the following documents ready (all must reflect your new legal name to process the change in our records): ☐ Court Order of Name Change ☐ Updated Government-Issued Photo ID (e.g., driver’s license, passport, or school photo ID if under 16) ☐ Updated Medical Insurance Card

Who is completing this form? *

Patient / Self
Legal Guardian

If you selected 'Legal Guardian' above, please provide your full name and your relationship to the patient.

Patient Information

Previous Legal Name *

First

Last

Date of Birth *

Phone *

Email *

Legal Name Change Request

Present Legal Name *

First

Last

Reason for Name Change (Select One):

Marriage
Divorce
Gender Transition
Other (Please specify on next line)

If you selected "Other" above, please specify the reason for the legal name change.

Required Documentation (Upload Section):

Court Order of Name Change, Updated Government-Issued Photo ID (license, passport, if under 16 school photo ID), Updated Medical Insurance Card (All documents must reflect the new legal name to process the change in our records.)

Court Order of Name Change File Upload *

Click or drag files to this area to upload. You can upload up to 3 files.

Updated Government-Issued Photo ID (license, passport, if under 16 school photo ID) *

Click or drag files to this area to upload. You can upload up to 3 files.

Updated Medical Insurance Card *

Click or drag files to this area to upload. You can upload up to 2 files.

Pronoun Preferences (Optional)

While legal documents must reflect your legal name, we want to ensure we address you correctly in person.

Your Preferred Pronouns (Select One):

She / Her
He / Him
They / Them
Other

If you selected "Other" above, please specify.

Section): Government-Issued Guardian'

Acknowledgment & Consent

Checkboxes *

I acknowledge that my legal name will be updated in DENT Neurologic Institute records only upon verification of the required legal documents.
I understand that my updated name and pronouns will be reflected in my medical records moving forward. However, past medical records will remain unchanged due to legal requirements.
I confirm that the information provided is accurate and authorize DENT Neurologic Institute to update my patient records accordingly.

Signature

Clear Signature

Date Signed

HIPAA & Practice Policy Acknowledgment

To complete your name change request, please download and sign our updated HIPAA and Practice Policies with your new legal name.

Upload Signed HIPAA & Practice Policies

Click or drag files to this area to upload. You can upload up to 4 files.

Signature

Clear Signature

Date Signed

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