Fillable (Please print clearly) TEXAS DEPARTMENT OF STATE HEALTH (Collin County Government)

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(Please print clearly) TEXAS DEPARTMENT OF STATE HEALTH (Collin County Government)

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Upon completion, please fax or mail form to the DSHS ImmTrac Group or a registered Health-care provider.
Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com Stock No. EF11-13366
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P.O. Box 149347 • Austin, TX 78714-9347 Revised 05/18/12
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
IMMUNIZATION REGISTRY (ImmTrac)
ADULT CONSENT FORM
Last Name
For Clinic/Office Use
First Name
M
iddle Name
Gender:
Male
Female
Date of Birth
- -
Address
A
partment #
Telephone
City
State
Zip Code
County
ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure
and confidential service that consolidates immunization records for public health purposes (e.g., giving all doctors treating a patient a central place to see that
patient’s immunization records). With your consent, your immunization information will be included in ImmTrac. For a family member younger than 18
years of age, a parent, legal guardian or managing conservator may grant consent for participation for that minor by completing the ImmTrac Minor
Consent Form (# C-7). The ImmTrac Minor Consent Form (# C-7) can be downloaded by visiting www.ImmTrac.com.
The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry.
Consent for Registration and Release of Immunization Records to Authorized Persons/Entities
I understand that, by granting the consent below, I am authorizing release of my immunization information to DSHS and I further
understand that DSHS will include this information in the state’s central immunization registry, ImmTrac. Once in ImmTrac, my
immunization information may by law be accessed by:
• a Texas physician, or other health care provider legally authorized to administer vaccines, for treatment of the individual as a patient;
• a Texas school in which the individual is enrolled;
• a Texas public health district or local health department, for public health purposes within their areas of jurisdiction;
• a state agency having legal custody of the individual;
• a payor, currently authorized by the Texas Department of Insurance to operate in Texas for immunization records relating to the
specific individual covered under the payor’s policy.
I understand that I may withdraw this consent at any time.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas immunization registry.
Individual (or individual’s legally authorized representative):
Printed Name
Date Signature
Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review
the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more
information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
PROVIDERS REGISTERED WITH ImmTrac – Please enter client
information in ImmTrac and affirm that consent has been granted.
D
O NOT
f
ax to ImmTrac
.
Retain this
f
orm in
y
our client’s record.
(Please print clearly)
DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS
REGISTRO DE VACUNAS (ImmTrac)
FORMULARIO DE CONSENTIMIENTO PARA ADULTOS
Apellido
Sólo para uso de la clínica/oficina
Primer Nombre
Segundo Nombre
Género:
Hombre
Mujer
F
echa de Nacimiento
- -
Dirección
A
partamento #
T
eléfono
Ciudad
Estado
Código Postal
Condado
ImmTrac, el registro de vacunas de Texas, es un servicio gratuito del Departamento Estatal de Servicios de Salud de Texas (DSHS). El
registro de vacunas es un servicio seguro y confidencial que consolida el récord de las vacunas para propósitos de salud pública (ej. darles
a todos los médicos que tratan a un paciente un lugar central para ver el récord de las vacunas de dicho paciente). Con su consentimiento,
su información de las vacunas se incluirá en ImmTrac. Para un familiar menor de 18 años de edad, uno de los padres, el tutor legal o el
custodio administrador puede dar el consentimiento de participación con llenar el Formulario de Consentimiento de ImmTrac para
menores de edad (# C-7). El Formulario de Consentimiento de ImmTrac (# C-7) se puede bajar del sito www.ImmTrac.com.
El Departamento Estatal de Servicios de Salud de Texas le invita a participar voluntariamente en el registro de vacunas de Texas.
Consentimiento para registrar y dar a conocer el recórd de las vacunas a las personas/entidades autorizadas
Entiendo que, al dar mi consentimiento a continuación, autorizo dar a conocer la información de mis vacunas al DSHS, y además
entiendo que el DSHS incluirá esta información en el registro central de las vacunas del estado, ImmTrac. Una vez que mi información de
las vacunas esté en ImmTrac, pueden por ley accederla:
• el médico u otro proveedor de salud de Texas legalmente autorizado para administrar vacunas para el tratamiento del individuo
como paciente;
• la escuela de Texas en la que el individuo está inscrito;
• el distrito de salud pública o el departamento de salud local de Texas, para propósitos de salud pública dentro de sus áreas de
jurisdicción;
• la agencia estatal que tenga la custodia legal del individuo;
• el pagador actualmente autorizado por el Departamento de Seguros de Texas para operar en Texas, con respecto al récord de las
vacunas relacionadas con el individuo cubierto según la póliza del pagador.
Entiendo que puedo retirar mi consentimiento en cualquier momento.
Con mi firma a continuación, DOY mi consentimiento para el registro. Deseo INCLUIR mi información de las vacunas en el
registro de vacunas de Texas, ImmTrac.
Individuo (o el representante legalmente autorizado del individuo):
Nombre en letra de molde
Fecha Firma
Notificación de privacidad: con ciertas excepciones, tiene derecho a pedir y a ser informado sobre la información que el estado de Texas reúne sobre usted. Tiene derecho a recibir y
examinar la información al pedirla. También tiene derecho a pedir a la agencia estatal que corrija cualquier información que se determine es incorrecta. Consulte
http://www.dshs.state.tx.us para obtener más información sobre la notificación de privacidad. (Referencia: Código gubernamental, sección 552.021, 552.023, 559.003 y 559.004)
Al rellenarlo, mándelo por fax o correo postal al Grupo ImmTrac del DSHS o a un proveedor de salud inscrito.
¿Tiene preguntas? (800) 252-9152 • (512) 776-7284 • Fax: Fax: (866) 624-0180 • www.ImmTrac.com Stock No. EF11-13366
Texas Department of State Health Services • ImmTrac Group – MC 1946 •P.O. Box 149347 • Austin, TX 78714-9347 Revised 05/18/2012
PROVIDERS REGISTERED WITH ImmTrac – Please enter client
information in ImmTrac and affirm that consent has been granted.
O NOT
ax to ImmTrac. Retain this
f
orm in
y
our client’s record.
(Favor de escribir claramente con letra de molde)
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(Please print clearly) TEXAS DEPARTMENT OF STATE HEALTH (Collin County Government)

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Completed 13 February 2021

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