Texas Immunization Registry Consent Form (Adult)

Texas Immunization Registry Consent Form (Adult)

ABC Pediatrics • 5333 W. University Drive, McKinney, TX 75071 • (972) 569-9904
The Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS). The Texas Immunization Registry is a secure and confidential service that consolidates and stores your immunization records. With your consent, your immunization information will be included in the Texas Immunization Registry. Doctors, public health departments, schools, and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed. For more information, see Texas Health and Safety Code Sec. 161.007 (d).

https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.007.
Patient Information
Patient Name*

FirstMiddleLast
Date of Birth*

MonthDayYear
Sex*

MaleFemale
Phone Number*
Please enter a valid phone number.
Email Address
Address*

Street Address

Apt Number

CityState

Zip Code
County*
Mother's Name

First NameMaiden Name
Race (Check all that apply)*

American Indian or Alaska NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhiteOther RaceDecline to Answer
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoDecline to Answer
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.
First Responders

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
First Responder

I am a FIRST RESPONDERI am an IMMEDIATE FAMILY MEMBER (older than 18 years of age) of a First Responder
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)
Signature

By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas Immunization Registry.
Signature of Individual (or Legally Authorized Representative)

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Printed Name
Date

MonthDayYear
Date
Should be Empty:

Texas Immunization Registry Consent Form (Adult)

Patient Information

Consent for Registration and Release of Immunization Records to Authorized Persons/Entities

First Responders

Privacy Notification

Signature