Get Az Adhs Immunization Record Request Form 2021-2025

Filling out the AZ ADHS Immunization Record Request Form online is a straightforward process. This guide will walk you through each section of the form, ensuring you complete it correctly and efficiently.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section labeled 'Immunization Record Requested For', provide the first name, middle name, last name, date of birth, and gender of the individual whose records you are requesting.
3. Next, complete the 'Current Address' and 'Phone Number' fields with accurate information to ensure proper communication.
4. Under 'Requestor’s Information', fill in your own name, relationship to the individual, current address, phone number, and email address. Ensure that the information is correct, as this will be used to verify your identity.
5. Authorize the Arizona Department of Health Services by signing your name in the designated area, along with the date of signing.
6. Indicate the recipient of the immunization records by choosing from options such as a doctor's office, school, or yourself. Provide any necessary contact details, including the fax number or email where records should be sent.
7. Once all necessary fields are filled out, review the form for accuracy, then save your changes. You can download, print, or share the form as needed.

Complete your AZ ADHS Immunization Record Request Form online today to ensure you receive your immunization records promptly.