Michigan Immunization Record Form PDF Details

Maintaining accurate health records is crucial for effective healthcare management, and in Michigan, the process for obtaining immunization records is streamlined through the Michigan Immunization Record Form. This form serves a vital function by enabling individuals or guardians to request an official State of Michigan Immunization Record. The form requires detailed information, including the individual's full name, date of birth, and gender, ensuring that records are accurately matched to requests. It is imperative that the requestor provides a photocopy of a current state-issued driver’s license or picture ID to verify their identity, a safeguard that underscores the state's commitment to privacy and security. The form also accommodates various scenarios, such as requests made by or for individuals under the age of 18, wherein the requester must outline their relationship to the child. For adults seeking their records, the request must be made personally. Social services agencies are also facilitated to make requests under specific conditions, highlighting the form’s adaptability to different needs. Additionally, the form requests updated contact information, ensuring that the immunization record is sent to the correct address. Finally, it outlines the submission process, which includes options for faxing or mailing the completed form, and notes a standard processing time, setting clear expectations for the requester. This comprehensive approach to immunization record requests illustrates Michigan’s dedication to accessible and secure healthcare documentation.

QuestionAnswer
Form NameMichigan Immunization Record Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmichigan immunization record form, michigan immunization records, official state of michigan immunization record, state of michigan immunization record

Form Preview Example

REQUEST FOR

OFFICIAL STATE OF MICHIGAN

IMMUNIZATION RECORD

PLEASE PRINT CLEARLY AND LEGIBLY

REQUESTED IMMUNIZATION RECORD INFORMATION

Last Name

First Name

Middle Name

Maiden Name

Date of Birth:

Month /

Day

/

Year

Gender:

Male Female

REQUESTOR’S INFORMATION (PERSON REQUESTING RECORD)

NOTE:

All requests MUST be accompanied with a photocopy of the requestor’s current state-issued driver’s license or picture I.D. or it will not be processed.

If the record requested is for a person under 18 years of age, please state your relationship to the child.

If the record requested is for a person 18 years of age or older, only the person named on the Immunization record may request a copy.

If the requestor is a social services agency, please provide a formal request with parental/legal guardian’s signature and a photocopy of their state-issued I.D., along with a photocopy of requestor’s state-issued I.D.

Requestor’s Name:

Requestor’s Relationship:

NOTE:

Have you recently moved? If so, please provide both old and new addresses. If not, provide current address. If you moved out-of-state, please provide your last known Michigan address.

Street

City

Zip Code

County

Old Current Address:

Street

City

State

Zip Code

New Address:

NOTE:

Has your telephone number recently changed? If so, please provide both the old and new number.

Old

Current

Area Code/Number

New Number:

Area Code/Number

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

Requestor’s Signature

 

 

Date

Instructions for completing this request: Please complete the form by printing all requested information as completely as

possible. International requests please include an email address. We cannot fax or phone internationally. Fax to: 517-335-9855

Mail to: Michigan Dept. of Health and Human Services-Immunization Program, PO Box 30195, Lansing, MI 48909. Please allow 14 business days for processing.

Office Use Only MCIR ID

Date mailed

Initials

 

 

 

This document is subject to revision or withdrawal at the discretion of the Michigan Department of Health and Human Services

Rev. 2-2016

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Writing section 1 of michigan immunization records

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