TX Immunization Registry Minor Consent

Texas Department of State Health Services

IMMUNIZATION REGISTRY (ImmTrac2) Minor Consent Form

Child's First Name

Child's Middle Name

Child's Last Name

Child's Date of Birth

Date

Child's Gender

MaleFemale

Child's Address

Apartment #

City

State

Zip Code

Telephone

County

Mother's First Name

Mother's Maiden Name

ImmTrac2, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS The immunization registry is a secure and confidential service that consolidates and stores your child's (younger than 18 years of age) immunization records. With your consent, your child's immunization information will be included in ImmTrac2. Doctors, public health departments, schools, and other authorized professionals can access your child's immunization history to ensure that important vaccines are not missed. The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry.

Consent for Registration of Child and Release of Immunization Records to Authorized Entities

I understand that, by granting the consent below, I am authorizing release of the child's immunization information to DSHS and I further understand that DSHS will include this information in the state's central immunization registry ("ImmTrac2" Once in (mmTrac2, the child's immunization information may by law be accessed by: a public health district or local health department, for public health purposes within their areas of jurisdiction; aphysician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient; a state agency having legal custody of the child; aTexas school or child-care facility in which the child is enrolled; a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may withdraw this consent to include information on my child in the ImmTrac2 Registry and my consent to release information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group - MC 1946, P. O. Box 149347, Austin, Texas 78714-9347.

By my signature below, I GRANT consent for registration. I wish to INCLUDE my child's information in the Texas immunization registry. Parent, legal guardian, or managing conservator: Printed Name

Printed Name

Signature

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.dsbusterac.com for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)

(512) 776-7284 Questions? (800) 252-9152 Texas Department of State Health ServicesAustin, TX 78714-9347 ImmTrac Group - MC 1946 . P. O. Box 149347

REGISTERED WITH PROVIDERSImmTrac2: and that PleaseenterclientinformationinImmTrac2affirmconsent

has been granted. DO NOT fax to ImmTrac2. Retain this form in your client's record.

Date

TEXAS