New York Adoption Information Registry Birth Parent Registration Form (Register or Submit Medical Information) (DOH-4065)
Official state formAdoptionForm DOH-4065Free downloadLast verified November 10, 2026
Notarized form a birth parent uses to register with the New York State Adoption Information Registry for identifying information or to submit medical information diagnosed after the adoption. It is returned to the Registry at the Department of Health in Albany.
Who can use this form
- A birth parent of a child who was placed for adoption.
- Registration for identifying information applies when the adoptee is 18 years of age or older.
- Medical information can be submitted with no age restriction.
- The signature must be notarized, with the notary's stamp or raised seal.
What to send with it
- The completed form with the box checked for each purpose.
- Medical information on the medical care provider's letterhead, with the provider's name, address, telephone number and signature.
- As much as you know about the child's birth, the agency where the child was placed and the court of adoption.
Where to send it
- Mail to
- New York State Department of Health Adoption Information Registry P.O. Box 2602 Albany, NY 12220-2602
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- 9/2000
- Source
- Official government page