Immtrac-2 Form

Immtrac-2 Form

You are providing information for the attached immunization registry form.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Telephone
Email address
Address
City State Zip Code
County
Mothers First Name
Mothers Maiden Name
Race - Select all that apply

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiin or Other Pacific IslanderWhiteRecipient RefusedOther
Ethnicity - Select only one

Hispanic or LatinoNot Hispanic or LatinoOther
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.
State law permits the inclusion of immunization records for First Responders and their immediate family members in the Texas
Immunization Registry. A “First Responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to
an emergency. An “immediate family member” is defined as a parent, spouse, child, or sibling who resides in the same household as the First
Responder. For more information, see Texas Health and Safety Code Sec. 161.00705. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.
htm#161.00705.

Please mark the appropriate box to indicate whether you are a First Responder or an Immediate Family Member.
First Responder

I am a First ResponderI am an IMMEDIATE FAMILY MEMBER (older than age 18) of a First Responder
By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas Immunization Registry.Individual (or individual’s legally authorized representative):

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Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects
about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct
any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference:
Government Code, Section 552.021, 552.023, 559.003, and 559.004)
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