In accordance with Public Act 540 of the Public Acts of 1996, Amended 2006, Act 91, the Michigan Department of
Health and Human Services (MDHHS) has established the Michigan Care Improvement Registry (MCIR) to record
information regarding childhood immunizations administered by health care providers. The information contained
in the MCIR is subject to confidentiality and disclosure requirements. The information in the MCIR shall be used
only for immunization purposes as authorized in state statutes and rules. Under the Public Act mentioned above,
providers shall report each immunization they administer to children born after January 1, 1994. This reporting
requirement is in effect unless the child’s parent or guardian or individual objects by written notice in accordance
with Sections 9206 and 9207 listed on the reverse side of this form.
Purpose -- Michigan Care Improvement Registry
The MCIR will collect standard, reliable information on the immunization status of individuals in Michigan. The
MCIR will enable private and public providers of immunization services to assess a person’s immunization status
and administer age-appropriate vaccinations. The MCIR will allow for reminder and recall notifications for persons
who are due or overdue for immunizations.
Statement -- Reporting Requirements of the MCIR
In accordance with Section 9206(3) of P.A. 540 of 1996 and Section 9207(3) of P.A. 91 of 2006:
I OBJECT to the reporting requirements of the MCIR and issue this written notification to the MDHHS
that immunization information for myself or my child not be reported to the MCIR. I understand that by
signing and submitting this form, no MCIR user will be able to record immunization information for me or
my child within the MCIR, nor will my or my child’s immunization history be available through the MCIR.
I RESCIND THE PREVIOUS OBJECTION to record immunization information for myself or my child
in the MCIR. I understand that by signing and submitting this form, the MCIR will resume recording
immunization information for my self or my child within the MCIR.
Person or Individual Information (this information is necessary to properly identify you or your child)
Last First Middle
MCIR ID ____________________________________________ Date of Birth___________________________
Parent/Guardian or Individual Contact Information
Last First Middle
Relationship to Child__________________________________ Phone Number (______)__________________
Signature____________________________________________________ Date _________________________
Name of Submitter____________________________________________________________________________
Completed forms must be sent to the appropriate MCIR Regional Office for processing.
This document is subject to revision or withdrawal at any time at the discretion of the Michigan Department of Health and Human Services.
Michigan Care Improvement Registry (MCIR)
Participation in the MCIR Reporting