Get Ma Mdph Miis Immunization Record Request 2022-2025

Filling out the MA MDPH MIIS Immunization Record Request online is a straightforward process that ensures you can obtain your immunization records efficiently. This guide provides clear steps to successfully complete the request form and submit it for processing.

Follow the steps to complete the immunization record request form.

1. Press the ‘Get Form’ button to retrieve the form and open it in a digital format.
2. Fill in the individual’s information in the section labeled 'Information on Record being requested.' Provide the full name, date of birth, gender, phone number, and address to ensure accurate identification.
3. If the record requested is for a person under 18 years of age, include the mother's maiden name in the required field.
4. Complete the 'Information on Requestor of the record' section. If you are requesting on behalf of the individual listed above, mark the box stating 'Requestor same as above' to skip this section or fill in the required details if you are different.
5. Indicate to whom the record should be released by selecting one of the options: 'SELF,' 'HEALTHCARE PROVIDER,' 'SCHOOL,' or 'OTHER.' If applicable, provide additional agency information such as name and phone number.
6. If you wish to receive confirmation of record processing via email, provide your email address. Alternatively, you can enter a fax number or phone number for confirmation.
7. Sign and date the form in the 'Signature of Requestor' section. Ensure that you certify that the information provided is accurate.
8. After completing the form, review all entries for accuracy and completeness. Save your changes before submitting.
9. You can now download, print, or share the filled-out form according to your need, and return the completed paperwork to MDPH by mail or fax.

Begin your online process to request your immunization records today.