REQUESTOR’S INFORMATION (PERSON REQUESTING RECORD)
Requestor’s Name: Requestor’s Relationship:
Current address:
Phone: ( ) -
E-mail:
By signing this agreement, I
hereby authorize the Arizona Department of Health Services
(print name of requestor)
(ADHS) to release immunization information that may be held by the Arizona State Immunization Information System
of the Arizona Department of Health Services. This information is to be released and sent to the following:
Recipient/To the Attention of:
Name of Organization:
Fax record to fax number:
Phone number: (
Email record to email address:
Requestor’s Signature:
Date:
/
/
Doctor's office/Health Care Provider
School
Daycare/Childcare center
Self
City:
State:
Zip:
(Records will be sent to you only if it is your record)
)
-
Once this form is completed, please print, sign and date. Send form along with supporting documents to ASIIS via Email, Fax
or Mail.
Email: ASIISHelpDesk@azdhs.gov
Fax: 602-364-3285 ATTN: ASIIS Records Request
Mail: Arizona Department of Health Services/Immunization Program-ASIIS
150 North 18th Ave., Suite 120
Phoenix, AZ 85007
If your records are found in our system we will send the records to the destination you requested above. If your records are
not found in our system, we will contact you.
IMMUNIZATION RECORD REQUESTED FOR:
First Name: Middle Name: Last Name:
Date of Birth: / /
Month Day Year
Gender: Male Female
Phone Number: (
) -
Current address:
City:
State:
Zip:
Immunization Record Request Form
Last Revision: July 2021
All immunization record requests must be accompanied by documents that identify the person requesting the
immunization record. Examples of acceptable forms of identification are a state-issued photo driver's
license with address, a state-issued photo identification card with address or a U.S. passport or passport
card with photo. Please lighten the copy of the ident
ification cards.
If the record requested is for a minor under 18 years of age, p
lease state your relationship to the minor in
the "Requestor's Relationship" field.
