Fillable Form Doh-4455 - Adoption Information Registry Birth Parent Registration Form (Page 2 of 2) in pdf

Adoption Information Registry Birth Parent Registration Form

NEW YORK STATE DEPARTMENT OF HEALTH

Vital Records Section

This form was developed in accordance with the provisions of Public Health Law section 4138-c(10).

Notice to Birth Parents

Do not complete this form for children born or adopted outside of New York State. The completed form will be submitted to the Court

by the agency or attorney handling the adoption. The Court will send it to the Adoption Registry.

This form allows you to choose whether or not you would like the Adoption Registry to provide your name and address ("identifying

information") to the adopted child. If you agree to the release of this information, the contact information will be provided to the child

only if he or she registers with the Adoption Registry. The child will be able to register once he or she has reached at least eighteen

years of age.

Checking

in item 4 on this form is not the same as giving consent to adoption or surrender. Whether you check

Yes

your consent to or acknowledgment of the adoption or surrender will still be legal.

If you do not check either

we will treat your answer as

unless we already have a completed form from you on file. In

Yes

that case, your previous choice will be retained and only your contact information will be updated.

You will not be notified if or when the Adoption Registry gives your information to the adopted child. It will be up to the adopted child

whether or not he or she will request information or contact you.

If both birth parents consented to the adoption or executed a surrender instrument, then each must complete one of these forms. If

either parent does not agree to the release of identifying information or later changes his or her mind and revokes agreement to the

release of identifying information, the Adoption Registry will not release the name and address of either parent to the adopted child.

If you change your mind in the future you can complete a new form and agree to the release of identifying information or cancel your

agreement by checking either

, having the form notarized and submitting the new form to the NYS Department of Health,

Yes

Adoption Information Registry, P.O. Box 2602, Albany, NY 12220-2602.

The adopted child will receive the most current name and address that you have on file with the Adoption Registry. To make sure the

child gets your current information, it is your responsibility to notify the Adoption Registry, in writing, if you change your name,

address or other information. You may use this form to notify the registry of changes in your contact information.

You can file medical information updates with the Adoption Registry. Medical information must be submitted on your medical care

provider’s letterhead and include: medical care provider’s name, address, telephone number and signature.

Further information about the services of the Adoption Registry and forms you can download can be found at

and

Adoption Agencies & Attorneys

For a child born in New York State, this form must be completed by the birth parent at the time the birth parent is either executing or

acknowledging a consent to adoption pursuant to section 115-b of the Domestic Relations Law or is executing a surrender instrument

pursuant to sections 383-c or 384 of the Social Services Law.

Completed forms must be filed with the court of adoption with the consent or instrument of surrender.

Court of Adoption

For a child born in New York State, this form must be completed by each birth parent at the time such birth parent is executing or

acknowledging a consent to adoption or is executing a surrender instrument for the relinquishment of the child named in this form.

Send the Report of Adoption (DOH-1928) or, for New York City, Notification of Order of Adoption (VR-47) and a copy of this form to:

Adoptee born in New York City:

Adoptee born elsewhere in New York State:

NYC Department of Health & Mental Hygiene

NYS Department of Health

Office of Vital Records

Vital Records Birth Amendment Unit

125 Worth St., Rm. 133, CN4

P.O. Box 2602

New York, NY 10013

Albany, NY 12220-2602

NYC Department of Health & Mental Hygiene

Send copies of this form, the Notification of Order of Adoption, the original birth certificate and the amended birth certificate to:

NYS Department of Health, Adoption Information Registry, P.O. Box 2602, Albany, NY 12220-2602

CLEAR FORM

DOH-4455 (10/2008)

Page 2 of 2

Form Doh-4455 - Adoption Information Registry Birth Parent Registration Form Page 2

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