Get Az Adhs Immunization Record Request Form 2016

Filling out the AZ ADHS Immunization Record Request Form online is a straightforward process aimed at ensuring you receive accurate immunization records. This guide breaks down each section of the form clearly to assist you in making your request efficiently.

Follow the steps to complete your request seamlessly.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by entering the person's details for whom the immunization record is requested. Fill in the first name, middle name, last name, and date of birth in the respective fields, ensuring to format the date correctly as month, day, and year.
3. Select the gender of the individual by marking either 'Male' or 'Female'.
4. Enter the current address, phone number, city, state, and zip code for the person for whom the record is being requested.
5. In the requestor’s information section, input your full name and relationship to the person whose record you are requesting. This is important if the individual is a minor under 18 years of age.
6. Complete your current address and contact information, including phone number, email, city, state, and zip code.
7. Authorize the Arizona Department of Health Services by printing your name in the designated area. This step confirms your consent to release the immunization information.
8. Indicate where you would like the records sent by selecting from the options given such as a doctor’s office, school, daycare, or your own self. Fill in any further details required, like fax number or email address of the recipient.
9. Finally, sign and date the form at the bottom after reviewing all provided information to ensure accuracy.
10. Once you have filled out the form, save any changes, and you can download, print, or share it as needed. Be sure to send the form along with any necessary identification to ASIIS via email, fax, or mail.

Begin your request for immunization records online today!