Fillable Clients Date of Birth client is less than (Collin County Government)

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Clients Date of Birth client is less than (Collin County Government)

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BROWSE COLLIN COUNTY GOVERNMENT (TX) FORMS

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Client’s Last Name
Client’s First Name Client’s Middle Name
/
/
Client’s Date of Birth
Client’s Address Apartment # Telephone
City State Zip Code County
Mother’s First Name (if client is less than 18 years of age) Mother’s Maiden Name (if client is less than 18 years of age)
ImmTrac, the Texas immunization registry, has been designated as the disaster-related reporting and tracking system for immunizations,
antivirals, and other medications administered to individuals in preparation for, or in response to, a disaster or public health emergency.
From the time the event is declared over, ImmTrac will retain disaster-related information received from health-care providers for a
period of 5 years. At the end of the 5 year retention period, client-specific disaster-related information will be removed from the Registry
unless consent is granted to retain the client information in ImmTrac beyond the 5 year retention period.
The Texas Department of State Health Services (DSHS) encourages your voluntary participation in the Texas immunization registry.
Consent for Retention of Disaster-Related Information and Release of Information to Authorized Entities
I understand that, by granting the consent below, I am authorizing retention of my (or my child’s) disaster-related information by DSHS
beyond the 5 year retention period. I further understand that DSHS will include this information in the state’s central immunization
registry (“ImmTrac”). Once in ImmTrac, my (or my child’s) disaster-related information may by law be accessed by:
• a state agency, for the purpose of aiding and coordinating communicable disease prevention and control efforts, and/or
• a physician or other health-care provider legally authorized to administer immunizations, antivirals, and other medications, for
treating the client as a patient;
I understand that I may withdraw this consent to retain information in the ImmTrac Registry beyond the 5 year retention period 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 to retain my disaster-related information (or my child’s information if under age 18)
in the Texas immunization registry beyond the 5 year retention period.
Client (or parent, legal guardian, or managing conservator:)
Printed Name
_______________________ _______________________________________________________________________________________
Date 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.dshs.state.tx.us for
more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004)
Upon completion, please fax or mail form to the DSHS ImmTrac Group or a registered Health-care provider.
Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com ImmTrac DC Stock No. EF11-12956
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P.O. Box 149347 • Austin, TX 78714-9347 Revised 05/18/2012
TEXAS
DEPARTMENT OF STATE HEALTH SERVICES
IMMUNIZATION
REGISTRY (ImmTrac)
DISASTER
INFORMATION RETENTION CONSENT FORM
*A parent, legal guardian or managing
conservator must sign this form if the
client is less than 18 years of age.
For Clinic/Office Use
(Please print clearly)
Client’s Gender: Male Female
PROVIDERS REGISTERED WITH ImmTrac – Please enter client
information in ImmTrac and affirm that consent has been granted.
DO NOT fax to ImmTrac. Retain this form in your client’s record.
click to sign
signature
click to edit
(Favor de escribir claramente con letra de molde)
Apellido
del Cliente
Nombre
del Cliente
Segundo Nombre
del Cliente
/
/
Fecha de Nacimiento
del Cliente
Dirección
del Cliente
Apartamento # Teléfono
Ciudad Estado Código Postal Municipio
Nombre de la Madre (si el cliente es menor de 18 años de edad) Apellido de Soltera de la Madre (si el cliente es menor de 18 años de edad)
ImmTrac, el registro de inmunización de Texas, ha sido designado como el sistema de información y seguimiento para inmunizaciones,
antivirales y otros medicamentos administrados a individuos durante la preparación o respuesta a un desastre o emergencia de salud
pública. A partir del momento en que se declare finalizado el evento, ImmTrac retendrá la información relacionada con el desastre
recibida por profesionales de la salud durante un periodo de 5 años. Al final del periodo de retención de 5 años, la información del cliente
relacionada con el desastre se removerá del registro a menos que se dé el consentimiento para retener la información en ImmTrac más
allá del periodo de retención de 5 años.
El
Departamento
Estatal de Servicios de Salud de Texas (DSHS) le anima a participar
voluntariamente
en el registro de inmunización de
Texas.
Consentimiento de retención de información relacionada con el desastre y dar a conocer la información a entidades autorizadas
Entiendo que, al dar mi consentimiento a continuación, autorizo al DSHS a que retenga mi información relacionada con el desastre (o la
de mi hijo[a]) más allá del periodo de retención de 5 años. Además entiendo que el DSHS incluirá esta información en el registro
central de inmunización del estado (“ImmTrac”). Una vez que mi información relacionada con el desastre (o la de mi hijo
[a]) esté en
ImmTrac, puede ésta por ley ser accedida por:
• las agencias estatales, con el propósito de ayudar con los esfuerzos de prevención y control de enfermedades transmisibles y
su coordinación y
• los médicos o demás profesionales de la salud legalmente autorizados para administrar vacunas, antivirales y otros medicamentos,
para el tratamiento del cliente como paciente.
Entiendo que puedo retirar el consentimiento para retener información en el registro ImmTrac más allá del periodo de retención de 5
años y mi consentimiento para dar a conocer la información del registro, en cualquier momento mediante comunicación escrita dirigida a
Texas Department of State Health Services, ImmTrac Group – MC 1946, P.O. Box 149347, Austin, Texas 78714-9347.
Con mi firma a continuación, DOY mi consentimiento para que se retenga mi información relacionada con el desastre (o la de mi
hijo[a] si es menor de 18 años de edad) en el registro de inmunizaciones de Texas más allá del periodo de retención de 5 años.
Cliente (o padre/madre, tutor legal o custodio administrador): _________________________________________________________
Escriba con letra de molde
_______________________ ________________________________________________________________________________
Fecha Firma
Notificación Sobre Privacidad: Tan solo por unas cuantas excepciones, usted tiene el derecho de solicitar y de ser informado sobre la información que
el Estado de Texas reúne sobre usted. A usted se le debe conceder el derecho de recibir y revisar la información al requerirla. Usted también tiene el
derecho de pedir que la agencia estatal corrija cualquier información que se ha determinado sea incorrecta. Diríjase a http://www.dshs.state.tx.us para
más información sobre la Notificación sobre privacidad. (Referencia: Government Code, sección 552.021, 552.023, 559.003 y 559.004)
Al rellenarlo, mándelo por fax o correo postal al Grupo ImmTrac del DSHS o a un proveedor de salud inscrito.
¿Tiene preguntas? (800) 252-9152 • (512) 776-7284 • Fax: Fax: (866) 624-0180 • www.ImmTrac.com ImmTrac DC Stock No. EF11-12956
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P.O. Box 149347 • Austin, TX 78714-9347 Revised 05/18/2012
*Uno de los padres, el tutor legal o
el custodio administrador debe firmar
este formulario si el cliente es menor
de
1
8años
de
edad.
For Clinic/Office Use
DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS
REGISTRO DE INMUNIZACIÓN (IMMTRAC)
FORMULARIO DE CONSENTIMIENTO DE RETENCIÓN DE
INFORMACIÓN SOBRE EL DESASTRE
PROVIDERS REGISTERED WITH ImmTrac – Please enter client
information in ImmTrac and affirm that consent has been granted.
DO NOT fax to ImmTrac. Retain this form in your client’s record.
Género: Masculino Femenino
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Completed 13 February 2021

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