Form DHS-1919 "Parent's Consent/Denial to Release Information to Adult Adoptee" - Michigan

What Is Form DHS-1919?

This is a legal form that was released by the Michigan Department of Health and Human Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2016;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-1919 by clicking the link below or browse more documents and templates provided by the Michigan Department of Health and Human Services.

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Download Form DHS-1919 "Parent's Consent/Denial to Release Information to Adult Adoptee" - Michigan

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PARENT’S CONSENT/DENIAL
TO RELEASE INFORMATION TO ADULT ADOPTEE
Michigan Department of Health and Human Services
Central Adoption Registry
A new statement may be sent to the Central
A separate form must be filled out for each child for whom
Adoption Registry any time to withdraw a previous
you are giving consent/denial.
consent or to withdraw a previous denial. Release
of identifying information will be based on the most
Send this original form and a copy of an approved photo
recent statement on file in the Central Adoption
identification to the Central Adoption Registry address below:
Registry.
MICHIGAN DEPARTMENT OF HEALTH
AND HUMAN SERVICES
A parent giving consent should send to the Central
CENTRAL ADOPTION REGISTRY
Adoption Registry a new statement if either his/her
PO BOX 30037
name or address changes.
LANSING MI 48909
I state that I am the
father
mother of the child described below.
I hereby
give consent
do not give consent* to the release of my name
and address to this child when he/she is 18 years of age or older.
(*If the denial box is checked, the parent may provide an explanation as to why he/she does not wish to
release name and address).
Reason:
A copy of an approved photo identification is included with this form. (Example: Current
driver’s license, current state issued photo identification or current student photo ID)
CHILD INFORMATION:
Child’s Full Name at Birth
Child’s Birth Date (Mo., Day, Yr.)
Child’s City of Birth
Child’s County of Birth
Child’s State of Birth
Child’s Birth Mother’s Name When Parental Rights were Released or Terminated
PARENT INFORMATION:
My Current Name
My Birth Date (Mo., Day, Yr.)
My Current Address (Street Number and Name)
Apartment or Lot Number
City
State
Zip Code
Telephone Number
Email
Signature
Date
The Michigan Department of Health and Human Services
AUTHORITY: MCLA 710.68.
(MDHHS) does not discriminate against any individual or group
because of race, religion, age, national origin, color, height,
COMPLETION: Voluntary.
weight, marital status, genetic information, sex, sexual orientation,
PENALTY: None
gender identity or expression, political beliefs or disability.
DISTRIBUTION: ORIGINAL - Michigan Department of Health and Human Services
Central Adoption Registry
PO Box 30037
Lansing, Michigan 48909
COPY -
Keep for your records.
DHS-1919 (Rev. 3-16) Previous edition obsolete.
PARENT’S CONSENT/DENIAL
TO RELEASE INFORMATION TO ADULT ADOPTEE
Michigan Department of Health and Human Services
Central Adoption Registry
A new statement may be sent to the Central
A separate form must be filled out for each child for whom
Adoption Registry any time to withdraw a previous
you are giving consent/denial.
consent or to withdraw a previous denial. Release
of identifying information will be based on the most
Send this original form and a copy of an approved photo
recent statement on file in the Central Adoption
identification to the Central Adoption Registry address below:
Registry.
MICHIGAN DEPARTMENT OF HEALTH
AND HUMAN SERVICES
A parent giving consent should send to the Central
CENTRAL ADOPTION REGISTRY
Adoption Registry a new statement if either his/her
PO BOX 30037
name or address changes.
LANSING MI 48909
I state that I am the
father
mother of the child described below.
I hereby
give consent
do not give consent* to the release of my name
and address to this child when he/she is 18 years of age or older.
(*If the denial box is checked, the parent may provide an explanation as to why he/she does not wish to
release name and address).
Reason:
A copy of an approved photo identification is included with this form. (Example: Current
driver’s license, current state issued photo identification or current student photo ID)
CHILD INFORMATION:
Child’s Full Name at Birth
Child’s Birth Date (Mo., Day, Yr.)
Child’s City of Birth
Child’s County of Birth
Child’s State of Birth
Child’s Birth Mother’s Name When Parental Rights were Released or Terminated
PARENT INFORMATION:
My Current Name
My Birth Date (Mo., Day, Yr.)
My Current Address (Street Number and Name)
Apartment or Lot Number
City
State
Zip Code
Telephone Number
Email
Signature
Date
The Michigan Department of Health and Human Services
AUTHORITY: MCLA 710.68.
(MDHHS) does not discriminate against any individual or group
because of race, religion, age, national origin, color, height,
COMPLETION: Voluntary.
weight, marital status, genetic information, sex, sexual orientation,
PENALTY: None
gender identity or expression, political beliefs or disability.
DISTRIBUTION: ORIGINAL - Michigan Department of Health and Human Services
Central Adoption Registry
PO Box 30037
Lansing, Michigan 48909
COPY -
Keep for your records.
DHS-1919 (Rev. 3-16) Previous edition obsolete.