IOCI 18-284
Printed by Authority of the State of Illinois
State of Illinois
I
llinois Department of Public Health
STATE OF ILLINOIS GENDER TRANSITION/INTERSEX CONDITION
APPLICATION INSTRUCTIONS
The Affidavit and Certificate of Correction Request form must be completed by the applicant and signed in the
presence of a notary public. The form is used for all corrections to birth, death, and fetal death records. We cannot
accept a letter or statement in place of this form. The original of the form must be submitted to this office along
with the completed Declaration of Gender Transition or Intersex Condition form.
The Declaration of Gender Transition or Intersex Condition form must be completed by either a licensed health
care professional or a licensed mental health professional, as defined by Section 1 of the Illinois Vital Records
Act (410 ILCS 535/1). This licensed professional must stipulate, under penalty of perjury, that the person
seeking a new certificate of birth has either undergone clinically appropriate treatment for gender transition or
has an intersex condition as required by 410 ILCS 535/17(1)(d).
A “Licensed health care professional” means a person licensed to practice as a physician, advanced
practice nurse or physician assistant in Illinois or any other state.
A “Licensed mental health professional” means a person who is licensed or registered to provide
mental health services by the Department of Financial and Professional Regulation or a board of
registration duly authorized to register or grant licenses to persons engaged in the practice of providing
mental health services in Illinois or any other state.
A name change must be accompanied by a certified copy of a court order entered by a court of competent
jurisdiction. Please indicate on your request to have your name changed in the second section of the Affidavit
and Certificate of Correction Request.
The Illinois Department of Public Health (IDPH) will review the request and if all requirements are met, will
create a new birth record reflecting the new sex designation and name change, if appropriate. The original birth
certificate and all documents submitted are placed in a sealed and impounded file which cannot be opened
except upon order of the circuit court, request of the person, or as provided by law or regulation.
The fee is $15 and includes one certified copy of the new birth certificate. Additional copies are $2 each if ordered
at the same time. Make check or money order payable to Illinois Department of Public Health.
Include a copy of your non-expired, government issued photo identification card (ID).
If you have additional questions, you can reach the Illinois Department of Public Health, Division of Vital
Records at 217-782-6553, Monday through Friday, 10 a.m. - 3 p.m. or via email to [email protected].
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
Division of Vital Records
925 E. Ridgely Avenue
Springfield, IL 62702-2737
IOCI 18-284
Printed by Authority of the State of Illinois
State of Illinois
I
llinois Department of Public Health
DECLARATION OF GENDER TRANSITION OR INTERSEX CONDITION
BY LICENSED HEALTH CARE PROFESSIONAL
State of _________________________:
County of ________________________:
I, _____________________________________________________ being a licensed health care professional
or a licensed mental health professional, have personally treated or evaluated
_____________________________________________________ and this person has either:
(Name of person treated or evaluated)
❑ undergone treatment that is clinically appropriate for the purpose of gender transition, based on
contemporary medical standards or,
❑ has an intersex condition.
The sex designation on such person’s birth record should therefore be changed to _____________________.
PHYSICIAN’S INFORMATION
License number _______________________ Issuing state________________ Expiration _____________
Office street address_______________________________________________________________________
Office city, state and ZIP code________________________________________________________________
Office telephone and facsimile numbers________________________________________________________
I declare, under penalty of perjury, that all of the foregoing information is true and correct.
Signature________________________________________________________________________________
(Licensed health care professional or licensed mental health professional)
