Request for Official State of Michigan Immunization Record at a glance
What it is: Request for official State of Michigan immunization record.
Who signs: Sign in Requestor's Signature.
What to bring and attach to Request for Official State of Michigan Immunization Record
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.
A filled-in Request for Official State of Michigan Immunization Record example: a parent requests a child's record
How to fill out Request for Official State of Michigan Immunization Record, box by box
Requested immunization record information
Print clearly and legibly the Last Name, First Name, Middle Name and Maiden Name of the requested immunization record.
Enter the Date of Birth as Month, Day and Year, and mark the Gender, Male or Female.
Requestor's Name and Relationship
If the record requested is for a person under 18 years of age, 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, 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.
Enter the Requestor's Name and the Requestor's Relationship.
Address
Have you recently moved? If so, provide both old and new addresses. If not, provide current address. If you moved out-of-state, provide your last known Michigan address.
Under Old Current Address, enter the Street, City, Zip Code and County.
Under New Address, enter the Street, City, State and Zip Code.
Telephone number
Has your telephone number recently changed? If so, provide both the old and new number.
Under Old Current Telephone Number, enter the Area Code/Number.
Under New Number, enter the Area Code/Number.
Requestor's signature and date
Sign in Requestor's Signature and enter the Date.
More rules for Request for Official State of Michigan Immunization Record
Complete the form by printing all requested information as completely as possible. International requests please include an email address. Cannot fax or phone internationally. Fax to: 517-335-9855
Common questions about Request for Official State of Michigan Immunization Record
Where do I file it?
Mail to: Michigan Dept. of Health and Human Services-Immunization Program, PO Box 30195, Lansing, MI 48909. Please allow 14 business days for processing.
Sources
[1] Request for Official State of Michigan Immunization Record (Rev. 2-2016), Michigan Department of Health and Human Services (the Official source link on this page).