REQUEST FOR WASHINGTON STATE CERTIFICATE OF IMMUNIZATION STATUS (CIS)

A completed Certificate of Immunization Status is required by WA State Law and for school attendance. Incomplete immunizations may result in exclusion from school.

The Washington State Immunization Law requires that any student entering a school district for the first time, must present to the school the dates (month, day, and year) of immunization against diphtheria, pertussis, tetanus, polio,
measles, mumps, and rubella (MMR), Varicella and Hepatitis B. Most requirements must be completed for Kindergarten Entry and presented to school prior to the start of school to prevent exclusion from school.

Additional Tdap dose is required for 6th grade (Middle School) entry. Documentation must be given to attending Middle School prior to the first day of school to prevent exclusion from school.

If our record shows that your child is missing a vaccine component that is required for school attendance, you will be notified and required to come to the office for a vaccine update before a CIS form can be generated.

Our vaccine policy can be found here.

Patient's Name *

First Name Last Name

Parent/Guardian/Authorized Representative Name *

First Name Last Name

Relationship / Capacity to Patient *

Patient's Date of Birth *

Month Day Year

Phone Number *

Area Code Phone Number

EMAIL ADDRESS *

How would you like to obtain the CIS form? *

Faxed directly to the school/child care facility Publish to patient portal Pick up at our office

If you would like the CIS to be faxed directly to the school/child care facility, please provide us with the fax number below:

Area Code Fax Number

Name of Facility

Phone number of Facility

In compliance with the The Health Insurance Portability and Accountability Act (HIPAA), please note that we are unable to send you the CIS form via email.

I understand that authorizing the disclosure of this Certificate of Immunization Status (CIS) is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

Signature of Patient / Parent / Guardian or Authorized Representative . (Guardian or Authorized Representative must attach documentation of such status.) *

Clear

Date of Request *

Month Day Year