Consent for Registration and Release of Immunization Records to Authorized Persons / Entities
I understand that, by granting the consent below, I am authorizing release of my immunization information to DSHS and I further
understand that DSHS will include this information in the Texas Immunization Registry. Once in the Texas Immunization Registry, my
immunization information may by law be accessed by: a Texas physician, or other health-care provider legally authorized to administer
vaccines, for treatment of the individual as a patient; a Texas school in which the individual is enrolled; a Texas public health district or local
health department, for public health purposes within their areas of jurisdiction; a state agency having legal custody of the individual; a payor,
currently authorized by the Texas Department of Insurance to operate in Texas for immunization records relating to the specific individual
covered under the payor’s policy. I understand that I may withdraw this consent at any time by submitting a completed Withdrawal of
Consent Form in writing to the Texas Department of State Health Services, Texas Immunization Registry.