REQUEST FOR
OFFICIAL STATE OF MICHIGAN
IMMUNIZATION RECORD
PLEASE PRINT CLEARLY AND LEGIBLY
REQUESTED IMMUNIZATION RECORD INFORMATION
Last Name First Name Middle Name Maiden Name
REQUESTOR’S INFORMATION (PERSON REQUESTING RECORD)
All requests MUST be accompanied with a photocopy of the requestor’s current
state-issued driver’s license or picture I.D. or it will not be processed.
If the record requested is for a person under 18 years of age, please state your
relationship to the child.
If the record requested is for a person 18 years of age or older, only the person named
on the Immunization record may request a copy.
If the requestor is a social services agency, please provide a formal request with
parental/legal guardian’s signature and a photocopy of their state-issued I.D., along with
a photocopy of requestor’s state-issued I.D.
Requestor’s Relationship:
Have you recently moved? If so, please provide both old and new addresses. If not, provide
current address. If you moved out-of-state, please provide your last known Michigan address.
Street City Zip Code County
Street City State Zip Code
Has your telephone number recently changed? If so, please provide both the old and new
number.
Old Current
Telephone Number:
Requestor’s Signature Date
Instructions for completing this request: Please complete the form by printing all requested information as completely as
possible. International requests please include an email address. We cannot fax or phone internationally. Fax to: 517-335-9855
Mail to: Michigan Dept. of Health and Human Services-Immunization Program, PO Box 30195, Lansing, MI 48909. Please allow 14
business days for processing.
Office Use Only
MCIR ID Date mailed Initials
This document is subject to revision or withdrawal at the discretion of the Michigan Department of Health and Human Services Rev. 2-2016
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