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In accordance with Public Act 540 of the (Michigan Care Improvement Registry)

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1
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)
Name___________________________________________________________________________ ___________
Last First Middle
MCIR ID ____________________________________________ Date of Birth___________________________
(MM/DD/YYYY)
Parent/Guardian or Individual Contact Information
Name______________________________________________________________________________________
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.
https://www.mcir.org/providers/regional-coordinators/contact-regions/
This document is subject to revision or withdrawal at any time at the discretion of the Michigan Department of Health and Human Services.
Rev 9-2015
Michigan Care Improvement Registry (MCIR)
Participation in the MCIR Reporting
2
Michigan Care Improvement Registry Law
MCL 540.9206
Section 9206 (1) The health care provider administering an immunizing agent to a child
shall present the person accompanying the child with a written certificate
of immunization, or make an entry of the immunization on a certificate in
the person’s possession. The certificate shall be in a form prescribed by
the department and shall indicate the diseases or infections for which the
child has been immunized, the number of doses given, the dates when
administered, and whether further immunizations are indicated.
Section 9206 (2) Before administering an immunizing agent to a child, a health care
provider shall notify the parent, guardian, or person in loco parentis of the
child, on a form provided by the department, of the right to object to the
reporting requirement of subsection (3).
Section 9206 (3) Unless the parent, guardian, or person in loco parentis of the child who
received the immunizing agent objects by written notice received by the
health care provider prior to reporting, a health care provider shall report
to the department each immunization administered by the health care
provider, pursuant to rules promulgated under section 9227. If the parent,
guardian, or person in loco parentis of the child who was immunized
objects to the reporting requirement of this subsection by written notice
received by the health care provider prior to notification, the health care
provider shall not report the immunization.
MCL 91.9207
Section 9207 (3) Upon receipt of a written request from an individual who is 20 years of
age or older, the department shall make any immunization information in
the registry pertaining to that individual inaccessible. The written request
shall be in a form prescribed or otherwise authorized by the department.
This document is subject to revision or withdrawal at any time at the discretion of the Michigan Department of Health and Human Services.
Rev. 9-2015
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In accordance with Public Act 540 of the (Michigan Care Improvement Registry)

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Completed 3 June 2021

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