Michigan Immunization Record Request Form
This file is a request form for obtaining an official immunization record from the Michigan Department of Health and Human Services. It contains fields for personal information, requestor information, address details, and signature. Follow the instructions to complete and submit the form.
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How do I fill this out?
To fill out this form, you need to provide the requested immunization record information, your contact details, and your signature. Make sure to include a photocopy of your state-issued driver's license or picture ID. Ensure all information is accurate and legible.
How to fill out the Michigan Immunization Record Request Form?
1
Provide the requested immunization record information.
2
Fill in your contact details and relationship to the individual (if applicable).
3
Include current and new addresses, if applicable.
4
Provide your old and current phone numbers, if applicable.
5
Sign the form and include a photocopy of your state-issued ID.
Who needs the Michigan Immunization Record Request Form?
1
Parents or legal guardians requesting vaccination records for their children.
2
Individuals requesting their own immunization records.
3
Social services agencies needing immunization records for clients.
4
Healthcare providers verifying immunization status for patients.
5
Schools and educational institutions confirming student vaccination records.
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What are the instructions for submitting this form?
To submit this form, please complete all required fields and include a photocopy of your state-issued driver's license or picture ID. You can fax the form to 517-335-9855 or mail it to: Michigan Dept. of Health and Human Services-Immunization Program, PO Box 30195, Lansing, MI 48909. Allow 14 business days for processing. It is important to provide accurate and complete information to avoid delays.
What are the important dates for this form in 2024 and 2025?
This form should be used when requesting immunization records for any date in 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to request an official immunization record from the Michigan Department of Health and Human Services. This form is necessary for individuals to obtain a copy of their vaccination history, which may be required for various purposes such as school enrollment, employment, or medical care. The form ensures that the requestor provides accurate information and includes the necessary documentation to process the request.
Tell me about this form and its components and fields line-by-line.
- 1. Last Name: Enter the last name of the individual whose record is being requested.
- 2. First Name: Enter the first name of the individual whose record is being requested.
- 3. Middle Name: Enter the middle name of the individual whose record is being requested.
- 4. Maiden Name: Enter the maiden name of the individual (if applicable).
- 5. Date of Birth: Enter the date of birth of the individual in Month/Day/Year format.
- 6. Gender: Select the gender of the individual (Male/Female).
- 7. Requestor's Name: Enter the name of the person requesting the record.
- 8. Requestor's Relationship: Describe the relationship of the requestor to the individual (parent, self, guardian, etc.).
- 9. Old Address: Enter the old address of the requestor (if applicable).
- 10. Current Address: Enter the current address of the requestor.
- 11. New Address: Enter the new address of the requestor (if applicable).
- 12. Old Telephone Number: Enter the old telephone number of the requestor (if applicable).
- 13. Current Telephone Number: Enter the current telephone number of the requestor.
- 14. New Telephone Number: Enter the new telephone number of the requestor (if applicable).
- 15. Requestor's Signature: The requestor must sign the form.
- 16. Date: Enter the date when the form is signed.
What happens if I fail to submit this form?
If you fail to submit this form correctly, your request for an immunization record may not be processed. Ensure all fields are completed accurately and a photocopy of your ID is included.
- Incomplete Information: Incomplete forms will not be processed, leading to delays in obtaining the immunization record.
- Missing Photocopy of ID: Requests without a photocopy of the state-issued ID will be rejected.
- Incorrect Addresses: Incorrect address information may lead to the record being sent to the wrong location.
How do I know when to use this form?
- 1. School Enrollment: Submit this form to obtain vaccination records required for school enrollment.
- 2. Healthcare Providers: Healthcare providers may need this form to verify a patient's immunization status.
- 3. Employment: Use this form to provide proof of immunizations required for employment.
- 4. Personal Records: Individuals may request their immunization records for personal record-keeping.
- 5. Legal Purposes: This form may be used to obtain immunization records for legal or court purposes.
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How long does it take to process the request for an immunization record?
Please allow 14 business days for processing after submitting the form.
What information do I need to provide to request a record for a minor?
You need to provide your relationship to the child and include a photocopy of your state-issued driver's license or picture ID.
Can I request an immunization record for someone over 18?
Only the person named on the immunization record can request a copy if they are 18 years of age or older.
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