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Get Massachusetts Immunization Request Form
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How to fill out the Massachusetts Immunization Request Form online
The Massachusetts Immunization Request Form allows individuals to request their or their child's immunization records from the Massachusetts Immunization Information System. This guide will assist you in completing the form accurately and efficiently.
Follow the steps to fill out the form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Provide the individual or child’s information. Fill in the first and last name, middle name if applicable, date of birth, gender, and mother's maiden name (if applicable for children under 18 years). Ensure this information is accurate to identify the individual correctly.
- Enter the contact information. Include a valid phone number for verification purposes, along with the street address, city, state, and ZIP code. This information is essential for the processing of your request.
- If you are filling out the form for a person under 18 or if you have legal authority to act on behalf of that person, provide your information as the parent, guardian, or provider. Include your name, relationship to the individual, your phone number, and address.
- If you are 18 years of age or older, sign and date the form. If you are completing the form on behalf of a minor or another individual, ensure that the legal guardian or authorized person signs the form.
- Prepare the additional documentation required. Include a photocopy of your driver’s license or state-issued ID with the ID number shielded or removed and a self-addressed stamped envelope for the return of the immunization record.
- After completing the form, make sure to review all entries for accuracy. Once confirmed, save changes, download, or print the form to submit it.
- Send the completed form along with the accompanying documents to the Massachusetts Department of Public Health at the specified address or fax number. Allow up to 10 business days for processing.
Complete your documents online today to ensure prompt processing.
You can request your immunization record through multiple avenues in Massachusetts. Typically, your healthcare provider or local health department can assist you. Additionally, by completing the Massachusetts Immunization Request Form, you can formally request your immunization record through authorized entities. This ensures you have the necessary paperwork for your health needs.
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