LETTER OF REQUEST FOR MEDICAL EXEMPTION
Dear (Name of Health Care Provider):
As the (mother/father/legal guardian) of the child named below, I am writing to request a
medical exemption from the vaccine(s) and listing the reason(s) below. To validate this
exemption request, I authorize and request you to provide supporting medical documentation
that this medical exemption is appropriate for (name of child) in West Virginia Statewide
Immunization Information System at https://www.wvimm.org/wvsiis/
or through typed
submission (handwritten submissions will not be accepted) of the form located at
http://www.dhhr.wv.gov/oeps/immunization/Documents/Medical%20Exemptions/WV_Med_Exe
mpt_Request_FILLABLE_Form%20_11.20.13.pdf If you need to contact me for additional
information concerning this request, please use the contact information provided below:
Name (parent/guardian):
Signature:
Name of child:
Child’s date of birth:
Address of parent/guardian:
Telephone and/or email of guardian:
Name of school and county:
Vaccinations for which an exemption is requested:
Describe or list the medical conditions, events or other reasons for which a medical
exemption is being requested (additional pages may be attached):
