Structure
The Michigan Immunization Record form serves as a crucial tool for individuals seeking to obtain their official immunization records from the state. This form requires clear and legible information, including the individual's last name, first name, middle name, maiden name, date of birth, and gender. It also collects details from the requestor, who must provide identification, such as a state-issued driver’s license or photo ID. For requests concerning individuals under 18, the relationship to the child must be specified, while those over 18 can only request their own records. The form prompts requestors to update any changes in address or telephone number, ensuring that the information is current. Additionally, social services agencies must include a formal request accompanied by signatures and identification from both the legal guardian and the agency. Instructions for submission are straightforward, with options for mailing or faxing the request, and a processing time of up to 14 business days is indicated. Overall, this form is designed to facilitate the efficient retrieval of immunization records while maintaining the privacy and security of personal information.
Form Example
REQUEST FOR
OFFICIAL STATE OF MICHIGAN
IMMUNIZATION RECORD
PLEASE PRINT CLEARLY AND LEGIBLY
REQUESTED IMMUNIZATION RECORD INFORMATION
Last Name |
First Name |
Middle Name |
Maiden Name |
Date of Birth:
Month / |
Day |
/ |
Year |
Gender:
Male 
Female
REQUESTOR’S INFORMATION (PERSON REQUESTING RECORD)
NOTE:
All requests MUST be accompanied with a photocopy of the requestor’s current
If the record requested is for a person under 18 years of age, please state your relationship to the child.
If the record requested is for a person 18 years of age or older, only the person named on the Immunization record may request a copy.
If the requestor is a social services agency, please provide a formal request with parental/legal guardian’s signature and a photocopy of their
Requestor’s Name:
Requestor’s Relationship:
NOTE:
Have you recently moved? If so, please provide both old and new addresses. If not, provide current address. If you moved
Street |
City |
Zip Code |
County |
Old Current Address:
Street |
City |
State |
Zip Code |
New Address:
NOTE:
Has your telephone number recently changed? If so, please provide both the old and new number.
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Old |
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Current |
Area Code/Number |
New Number: |
Area Code/Number |
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Telephone Number: |
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Requestor’s Signature |
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Date |
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Instructions for completing this request: Please complete the form by printing all requested information as completely as
possible. International requests please include an email address. We cannot fax or phone internationally. Fax to:
Mail to: Michigan Dept. of Health and Human
Office Use Only MCIR ID |
Date mailed |
Initials |
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This document is subject to revision or withdrawal at the discretion of the Michigan Department of Health and Human Services |
Rev. |
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Document Specs
| Fact Name | Details |
|---|---|
| Purpose | The Michigan Immunization Record form is used to request an official immunization record from the state. |
| Eligibility | Individuals aged 18 or older can request their own records. For those under 18, a parent or legal guardian must request the record. |
| Required Identification | A photocopy of the requestor's current state-issued driver’s license or picture I.D. is mandatory for processing. |
| Submission Methods | Requests can be submitted via fax or mail. Fax submissions should go to 517-335-9855, while mailed requests should be sent to the Michigan Dept. of Health and Human Services. |
| Processing Time | Requests are typically processed within 14 business days. |
| Address Changes | If the requestor has moved, both old and new addresses must be provided. This includes the last known Michigan address for out-of-state moves. |
| Telephone Number Changes | Requestors must indicate if their telephone number has changed, providing both old and new numbers if applicable. |
| Governing Law | The form is governed by Michigan Public Health Code, Act 368 of 1978, particularly sections related to immunization records. |
| Office Use Only | The form includes a section for office use, which captures the MCIR ID, date mailed, and initials of the processing staff. |
| Form Revision | This document is subject to revision or withdrawal at the discretion of the Michigan Department of Health and Human Services. |
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