Washington Court Order Parentage Supplemental Information Form (DOH 422-164)
Official state formParentage and paternityForm DOH 422-164Free downloadLast verified November 10, 2026
This form goes with a certified court order so the Washington State Department of Health can add or remove a parent on a birth certificate, or change the child's name as the order instructs. It is mailed to the Center for Health Statistics.
Who can use this form
- A person sending a court order that adds a parent to, or removes a parent from, a Washington birth certificate
- It also covers a child's legal name change when the court order instructs it
What to send with it
- The completed form, filled out in ink
- The certified court order
- Optional: a completed certificate order form with the documents it requires
- Optional: a certified copy issued less than one year ago, to exchange it at no charge
Where to send it
- Mail to
- Center for Health Statistics PO Box 47814 Olympia, WA 98504-7814
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- May 2021
- Source
- Official government page