TX Immunization Registry Adult Consent

TEXAS
Texas Department of State Health Services

TEXAS IMMUNIZATION REGISTRY ImmTrac2)
ADULT CONSENT FORM
Name

First NameMiddle NameLast Name
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
Gender

FemaleMale
Telephone
Email address
example@example.com
Address
Apartment # / Building #
City
State
Zip Code
County
Mother's First Name
Mother's Maiden Name
Race (select all that apply)

American Indian or Alaska NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhiteOther RaceRecipient Refused
Ethnicity (select only one)

Hispanic or LatinoNon Hispanic or LatinoRecipient Refused
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 immunization records for public health purposes (e.g., giving all doctors treating a patient a central place to see that patient's immunization records With your consent, your immunization information will be included in ImmTrac2. For a family member younger than 18 years of age, a parent, legal guardian, or managing conservator may grant consent for participation for that minor by completing the ImmTrac2 Minor Consent Form (# C-7) available for downloading at www.ImmTrac.com.

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 ImmTrac2, 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 individualasapatient; aTexasschool 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.

State law permits the inclusion of immunization records for First Responders and their immediate family members (older than 18 years ofin age)

the 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 a family member younger than 18 years of age, a parent, legal guardian, or managing conservator may grant consent for participation as an "ImmTrac2 child" by completing the Immunization Registry (ImmTrac2) Consent Form (# C-7
Please mark the appropriate box to indicate whether you are a First Responder or an Immediate Family Member.

I am a FIRST RESPONDER.I am an IMMEDIATE FAMILY MEMBER (older than 18 years of age) of a First Responder.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas immunization registry.
Printed Name
Individual (or individual's legally authorized representative):
Signature

Clear
Date

MonthDayYear
Date
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.drbs.texas.gom for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
Texas Department of State Health Services
PROVIDERS REGISTERED WITH Imm Trac2: Please enter client information in mmTTrac2 and affirm that consent has been granted. DO NOT fax to ImmTrac2. Retain this form in your client's record.
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TEXAS

ADULT CONSENT FORM