ImmTrac Forms and Documents

General/Miscellaneous Consent Forms: 
ImmTrac - Immunization Registry Consent Form (rev. 05/2012)
Use this form to register your child, aged 17 and younger, in ImmTrac.
Birth registrars: DO NOT use this form. See F11-11936 below.
ImmTrac Adult Consent Form (rev. 05/2012)
Use this form to register as an adult (aged 18 and older) in ImmTrac.
ImmTrac First Responder/First Responder Family Member Consent Form (rev. 05/2012)
Use this form to register as a first responder and first responder family members, aged 18 and older.
ImmTrac Disaster Information Retention Consent Form (rev. 05/2012)
Use this form to retain your disaster-related informationn beyond 5 years.
Request an Immunization Record:
Authorization to Release ImmTrac History Form (rev. 04/2012)
Use this form to authorize release of your or your child's ImmTrac records. 
Newborn Consent Form:
ImmTrac Newborn Registration Form (rev. 04/2014)
Use this form to grant or deny newborn registration in ImmTrac.
For use by birth registrars only.
ImmTrac Withdrawal Form:
Withdrawal of Consent and Confirmation Form (rev. 04/2014)
Use this form to withdraw your child or yourself from participation in ImmTrac.

Forms for Providers & Payors:
Documents for Providers & Payors:
Providers:

Payors:


General Fact Sheets:

Helpful Links: