I authorize Tribal Health to collect and enter immunization records for the listed patient into the Department of Public Health and Human Services Immunization Information records (ImMTrax). ImMTrax is a confidential computer system that contains immunization records. I understand that information in the registry may be released to a public agency, the patient’s healthcare provider(s), and other facilities such as schools. I understand that I can revoke my authorization and have my record removed at any time by contacting my local Health Department. By signing below, I agree to allow immunization information to be entered into ImMTrax.