District of Columbia Immunization Information System (DOCIIS

District of Columbia Immunization Information System (DOCIIS)

Authorization to Release Immunization Record Form

MAIL TO: DC Department of Health Immunization Program FAX TO: (202) 576-6418

899 North Capitol Street, NE Email: doh.immunization@dc.gov

Washington, D.C. 20002

Section I Patient Information

(Record requests expire 30 days after the date the requestor authorized and signed the release form.)

Patient Name:

Last First Middle

Other Name(s) Used: Date of Birth: / /

MM DD YY

Address:

Street Apt. City State Zip Code

Section II Receiving Person or Agency (Where to send the official immunization record)

Person/Agency to Receive Immunization Record:

Phone: ( ) Fax: ( ) Email:

Mailing Address:

Street Apt. City State Zip Code

Immunizations Should be Sent to the Listed: [] Fax [] Mailing Address [] Secure Email OR [] I will pick up

Section III Requestor Information

(All requests MUST be accompanied with a photocopy of requestor’s current state issued ID or picture ID)

Requestor Name:

Last First Middle

Phone Number: ( ) Relationship to Patient: [] Self [] Parent [] Guardian Reason for Request

Address:

Street Apt. City State Zip Code

Supporting Documentation: [] Driver’s License [] Court Order Granting Guardianship [] Non-Driver’s ID

[] Release of Information [] Work ID [] Student ID [] Other:

I request and authorize the DC Immunization Program to release this patient’s official immunization record from the District of Columbia Immunization

Information System (DOCIIS), to the person/agency above. I declare that the foregoing is true and correct, and that I am authorized to sign this release

on the patient’s behalf. I understand that not all providers in the District submit information to DOCIIS and there is a chance that my child’s or my

record may not be found in DOCIIS or the record may have incomplete information. I understand that the requested information will be faxed, or

mailed to the designated number or address listed above or may be picked up by designated person/agency.

Signed On: / /

Signature of Parent/Legal Guardian or Patient ( if 18 yrs of age or older)

Section IV For Official Use Only

Received: / / [] Records Released [] Record Not Found [] Record Found But No Immunizations Reported

Record Released: / / Check One: Faxed Mailed Emailed Hand Delivered

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