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The Michigan Immunization Record form is a crucial document for individuals seeking to obtain official immunization records from the state. This form requires personal information, including the individual’s last name, first name, middle name, maiden name, date of birth, and gender. It also collects the requestor's information, ensuring that requests are legitimate and properly authorized. For those requesting records for minors, the relationship to the child must be specified. Additionally, the form mandates that requestors provide a photocopy of their current state-issued driver’s license or picture ID to validate their identity. If the requestor is a social services agency, specific documentation is required, including a formal request signed by a parent or legal guardian. The form also includes sections for address updates and changes to contact information, which are essential for accurate record processing. It is important to complete the form legibly and to follow the submission instructions carefully, as incomplete requests may lead to delays. Upon submission, individuals can expect processing to take approximately 14 business days.
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REQUEST FOR
OFFICIAL STATE OF MICHIGAN
IMMUNIZATION RECORD
PLEASE PRINT CLEARLY AND LEGIBLY
REQUESTED IMMUNIZATION RECORD INFORMATION
Last Name |
First Name |
Middle Name |
Maiden Name |
Date of Birth:
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Year |
Gender:
Male Female
REQUESTOR’S INFORMATION (PERSON REQUESTING RECORD)
NOTE:
All requests MUST be accompanied with a photocopy of the requestor’s current
If the record requested is for a person under 18 years of age, please state your relationship to the child.
If the record requested is for a person 18 years of age or older, only the person named on the Immunization record may request a copy.
If the requestor is a social services agency, please provide a formal request with parental/legal guardian’s signature and a photocopy of their
Requestor’s Name:
Requestor’s Relationship:
NOTE:
Have you recently moved? If so, please provide both old and new addresses. If not, provide current address. If you moved
Street |
City |
Zip Code |
County |
Old Current Address:
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City |
State |
Zip Code |
New Address:
NOTE:
Has your telephone number recently changed? If so, please provide both the old and new number.
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New Number: |
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Requestor’s Signature |
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Instructions for completing this request: Please complete the form by printing all requested information as completely as
possible. International requests please include an email address. We cannot fax or phone internationally. Fax to:
Mail to: Michigan Dept. of Health and Human
Office Use Only MCIR ID |
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This document is subject to revision or withdrawal at the discretion of the Michigan Department of Health and Human Services |
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Form Specifications
| Fact Name | Details |
|---|---|
| Form Purpose | The Michigan Immunization Record form is used to request an official immunization record from the state of Michigan. |
| Eligibility | Individuals 18 years or older can request their own records. For minors, a parent or legal guardian must make the request. |
| Identification Requirement | All requests must include a photocopy of the requestor's current state-issued driver’s license or picture ID. |
| Processing Time | Requests are typically processed within 14 business days from the date of receipt. |
| Governing Law | The issuance of immunization records is governed by the Michigan Public Health Code (Act 368 of 1978). |
| Submission Methods | Requests can be submitted via fax or mail to the Michigan Department of Health and Human Services. |
Michigan Immunization Record: Usage Guidelines
Filling out the Michigan Immunization Record form is a straightforward process that requires careful attention to detail. Once completed, this form can be submitted to obtain the necessary immunization records. Follow these steps to ensure you provide all the required information correctly.
- Print the form clearly: Begin by writing your information in clear, legible print to avoid any processing delays.
- Fill in the requested immunization record information: Include the last name, first name, middle name, and maiden name (if applicable) of the individual whose immunization record you are requesting.
- Provide the date of birth: Enter the date of birth in the format of month/day/year.
- Select gender: Mark the appropriate box for male or female.
- Complete requestor’s information: Fill in your name and relationship to the individual if they are under 18 years old. If the individual is 18 or older, only they can request the record.
- Address details: If you have moved recently, provide both your old and new addresses. If you haven't moved, list your current address only. Include the street, city, state, zip code, and county.
- Telephone number: Indicate if your phone number has changed. Provide both the old and current numbers if applicable.
- Attach identification: Include a photocopy of your current state-issued driver’s license or picture ID. This is mandatory for processing your request.
- Sign and date the form: Make sure to sign and date the form before submission.
- Submit the form: Fax the completed form to 517-335-9855 or mail it to the Michigan Department of Health and Human Services-Immunization Program, PO Box 30195, Lansing, MI 48909. Allow 14 business days for processing.
Your Questions, Answered
What is the Michigan Immunization Record form used for?
The Michigan Immunization Record form is used to request an official copy of an individual's immunization records from the state of Michigan. This record is important for various purposes, such as school enrollment, employment requirements, or travel. It provides a comprehensive overview of the vaccinations a person has received.
Who can request an immunization record?
Only specific individuals can request an immunization record. If the person is under 18 years old, a parent or legal guardian must make the request. For individuals 18 years or older, only the person named on the record can request a copy. If a social services agency is requesting the record, they must provide a formal request along with the necessary signatures and identification.
What information do I need to provide on the form?
When completing the form, you must provide the individual's full name, date of birth, and gender. Additionally, the requestor's information, including name, relationship to the individual, and current address, is required. If you have moved recently, both old and new addresses should be included. A photocopy of the requestor's state-issued ID must also accompany the request.
How long does it take to process the request?
Requests for the Michigan Immunization Record typically take about 14 business days to process. It is important to allow sufficient time for the request to be completed, especially if you need the record for an upcoming deadline.
What should I do if I have moved out of state?
If you have moved out of Michigan, you should still provide your last known Michigan address on the form. This information helps the state locate your records more efficiently. Make sure to include your current address as well, especially if you are requesting the record from a different state.
Can I submit the request by fax or email?
Requests cannot be submitted via email or fax internationally. However, you can fax your request to 517-335-9855 if you are in the United States. For all requests, ensure that you follow the instructions carefully and include all required information and documentation to avoid delays.
Common mistakes
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Illegible handwriting: Many people do not print clearly. This can lead to misunderstandings or incorrect information being processed.
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Missing identification: Failing to include a photocopy of a current state-issued driver’s license or picture I.D. will result in the request not being processed.
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Incorrect relationship disclosure: When requesting records for someone under 18, it’s essential to clearly state your relationship to the child.
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Omitting address changes: If you have moved recently, both your old and new addresses must be provided. Omitting this information can delay processing.
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Not updating phone numbers: If your phone number has changed, you need to include both the old and new numbers. This ensures that you can be contacted if needed.
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Ignoring the processing time: People often forget that it can take up to 14 business days for the request to be processed. Planning ahead is important.
Documents used along the form
The Michigan Immunization Record form is often accompanied by several other important documents that facilitate the processing of requests and ensure accurate information is provided. Below is a list of related forms and documents commonly used in conjunction with the immunization record request.
- Proof of Identity: A photocopy of the requestor's current state-issued driver’s license or picture I.D. is required to verify identity and authorize the release of records.
- Parental Consent Form: For requests made on behalf of individuals under 18 years old, this form must be signed by a parent or legal guardian, affirming their consent to access the immunization records.
- Authorization for Release of Information: This document allows healthcare providers to share immunization records with the requestor. It must be signed by the individual whose records are being requested.
- Change of Address Notification: If the requestor has moved, this document provides updated address information to ensure records are sent to the correct location.
- Request for Medical Records: In some cases, a broader request for medical records may be necessary, which can include immunization records among other health information.
- Social Services Agency Request Form: If a social services agency is requesting records, this formal request must include the signature of a parent or legal guardian along with their identification.
- International Request Form: For individuals residing outside the United States, this form is necessary to provide additional contact information, as international requests cannot be processed via fax or phone.
Each of these documents plays a crucial role in the process of obtaining immunization records in Michigan. Ensuring that all necessary forms are completed accurately can help streamline the request process and avoid delays.
Similar forms
- Vaccination Record: Similar to the Michigan Immunization Record, this document provides a detailed account of a person's vaccinations, including dates and types of vaccines received.
- Health Record: A comprehensive overview of an individual's health history, including immunizations, allergies, and past medical conditions, often used for school or employment requirements.
- School Health Form: This form is commonly required by schools to ensure that students are up to date on their vaccinations and to maintain a safe environment for all students.
- Travel Vaccination Certificate: Issued for international travel, this document verifies that a traveler has received necessary vaccinations, similar to how the Michigan form verifies immunization status.
- Child's Medical Record: Contains a child's complete medical history, including immunization details, and is often requested by parents for continuity of care.
- Employee Health Record: Employers may require this document to ensure that employees are vaccinated against certain diseases, mirroring the requirements of the Michigan Immunization Record.
- Patient Immunization History: Similar to the Michigan form, this document is often provided by healthcare providers to summarize a patient's vaccination history for easy reference.
- State Immunization Registry Record: Maintained by state health departments, this record tracks immunizations received by individuals, similar to the Michigan Immunization Record.
- School Enrollment Form: Often requires proof of immunizations, aligning with the Michigan form's purpose of confirming vaccination status for school-aged children.
- Public Health Immunization Record: A document issued by public health agencies that outlines an individual's immunization history, akin to the Michigan Immunization Record.
Dos and Don'ts
When filling out the Michigan Immunization Record form, it is important to follow specific guidelines to ensure accurate processing. Below is a list of things you should and shouldn't do.
- Do print clearly and legibly.
- Do include a photocopy of your current state-issued driver’s license or picture I.D.
- Do specify your relationship to the child if requesting for someone under 18 years old.
- Do provide both old and new addresses if you have recently moved.
- Do include both old and new telephone numbers if your number has changed.
- Do allow 14 business days for processing after submission.
- Don't submit the form without a valid identification photocopy.
- Don't request records for individuals over 18 unless you are the person named on the record.
- Don't forget to sign and date the request form before submission.
Following these guidelines will help ensure that your request is processed efficiently and without delays.
Misconceptions
Understanding the Michigan Immunization Record form can be challenging. Here are seven common misconceptions about this important document:
- Anyone can request an immunization record. Only the individual named on the record or their legal guardian can request it. For minors, the relationship to the child must be stated.
- A request can be made without identification. All requests must include a photocopy of the requestor’s current state-issued driver’s license or picture I.D. Requests without this will not be processed.
- There is no need to provide old addresses. If you have moved recently, both your old and new addresses must be provided on the form.
- Requests can be made by phone or fax internationally. The Michigan Department of Health and Human Services does not accept phone or fax requests from outside the U.S. An email address is required for international requests.
- Processing time is immediate. Please allow up to 14 business days for your request to be processed. Planning ahead is essential.
- All information on the form is optional. Completing all requested information is crucial for processing your request smoothly. Incomplete forms may lead to delays.
- Only one copy of the record can be obtained. You may request multiple copies, but each request must be submitted separately with the required documentation.
By clarifying these misconceptions, you can ensure a smoother process when requesting your immunization record.
Key takeaways
Key Takeaways for Filling Out and Using the Michigan Immunization Record Form:
- Print all information clearly and legibly to ensure accurate processing.
- Include a photocopy of your current state-issued driver’s license or picture I.D. with your request.
- If requesting for a child under 18, indicate your relationship to the child.
- Only individuals 18 years or older can request their own immunization records.
- Social services agencies must submit a formal request with the legal guardian’s signature and I.D.
- Provide both old and new addresses if you have recently moved.
- Update your telephone number if it has changed, including both old and new numbers.
- Allow 14 business days for processing after submitting your request.