Fillable Petition for Modification Form - Immunization Correction (Michigan Care Improvement Registry)

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Petition for Modification Form - Immunization Correction (Michigan Care Improvement Registry)

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The Petition for Modification Form - Immunization Correction (Michigan Care Improvement Registry) form is 1 page long and contains:

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  • 10 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

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Petition for Modification Form - Immunization Correction
Please fax completed forms to the MCIR Region Two Help Desk 1-269-373-5079
Providers may only request modification to immunization data for those shots that were not entered by their office. If the
data is underlined in the history screen, you have the ability to edit the immunization data. All other immunization data that is
not underlined was entered by other health care providers and cannot be modified by you. These doses can only be
modified by a request to the regional MCIR office
If the data is not underlined, this form is required along with a copy of the documentation (e.g., copy of the shot record)
supporting this change. On the Petition, please provide:
1) Vaccine name (e.g., DTP, Polio, etc.)
2) MCIR shot date
3) Correct vaccine and date
4) Check either “Modify” or “Delete”
5) Putting the phrase “See Attached” is not acceptable. Each shot modification MUST BE specified in detail on the
Petition.
6) EXCEPTION: If you find duplicate shot data under the same vaccine, you may request that the duplicate dates be
deleted. Simply put “Duplicate Dates” in the “Correct Date” box. You do not have to submit a copy of
documentation to make this particular request.
Attach additional sheets if needed. Documentation is required to make any changes to MCIR shot dates.
All boxes in both the “Requestor’s Information” and the “Person Information” sections MUST be
completed. Failure to do so will delay the processing of this request.
SECTION 1 - Requestor’s Information (please print or type)
Name of Provider/Practice
County Practice is Located In
Area Code + Phone Number
Person Completing Form
Email Address
Area code + Fax Number
SECTION 2 - Person Information (as it currently appears in MCIR – Please Print/Type)
Name (Last, First, Middle, Suffix, etc.)
Date of Birth
(mm/dd/yyyy)
MCIR Person ID
Gender
Female
SECTION 3 - Complete the Section Below to Change/Delete Immunization Data (include documentation):
Current Vaccine (as it appears in
MCIR)
Current MCIR Date
(mm/dd/yyyy)
Correct Vaccine
(if applicable)
Correct Date
(mm/dd/yyyy)
Check Below
Modify
Delete
FOR MCIR USE ONLY
Date Received:
Date Corrected:
Staff Initials:
Rev. 12/15/15
Modify
Delete
Modify
Delete
Modify
Delete
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Petition for Modification Form - Immunization Correction (Michigan Care Improvement Registry)

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Completed 3 June 2021

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