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STATE OF MONTANA - PREMARITAL TESTING FOR RUBELLA (Rosebud County)

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STATE OF MONTANA - PREMARITAL TESTING FOR RUBELLA IMMUNITY
(Section 40-1-203, MCA)
(Administrative Rules of Montana Title 37, Chapter 12, Subchapter 601)
Pursuant to Montana law, as referenced above, applicants for a marriage license must file a medical certificate evidencing
a blood test for rubella immunity of the female applicant or a medical exemption to the blood testing requirement (Section
A). In the alternative, a waiver of the requirement for a blood test shall be granted upon receipt of a statement of informed
consent pertaining to the need for rubella immunity testing for the female applicant prior to pregnancy, yet declining
premarital testing (Section B). The appropriate Section must be completed as indicated, and this document must be signed
by both applicants.
A. MEDICAL CERTIFICATE OF BLOOD TESTING OR MEDICAL EXEMPTION
Procedure if Examination is Made in the State of Montana
1. The female applicant for a marriage license consults a physician for blood tests. If required, the physician sends a
specimen of the applicant's blood to an approved laboratory.
2. After careful examination of the laboratory report, the report is exhibited to and examined by both the applicant and the
other party to the proposed marriage contract. The physician will then complete this Certificate, sign it and present it to the
applicant.
3. If the rubella test is not required, the physician so indicates on this Certificate, signs it, and presents it to the applicant.
4. Both applicants sign this document at the bottom and present it to the Clerk of the District Court who issues the marriage
license.
Procedure if Examination is Made Outside the State of Montana
1. Premarital Certificate Forms are available from the Montana Department of Public Health & Human Services, Helena,
MT. www.dphhs.mt.gov
2. The applicant may consult any duly licensed physician in any State or Territory or Canadian Province for the
examination.
3. Blood tests made outside the state must be done in approved laboratories which include State and Territorial Health
Department laboratories and laboratories within their jurisdictions approved by them, U.S. Public Health Service
laboratories, laboratories operated by the U.S. Armed Forces and Veteran's Administration, Provincial Public Health
Laboratories of Canada, and laboratories licensed under the provision of the Clinical Laboratories Improvement Act of
1988.
4. Certificate Forms provided by other states having comparable laws will be accepted for persons who have received blood
tests outside of Montana.
This is to certify that: _________________________________________________________
(Full name of applicant)
______ 1. Has submitted to a blood test for rubella immunity. The test was performed at:
________________________________________________________
(Name of laboratory)
_________________________________________________________
(Address of laboratory)
______ 2. Is exempt on medical grounds and is not required to submit a blood test for rubella immunity.
_________________________________________________________
(Signature of Physician)
_________________________________________________________
(Address of Physician)
Physician not licensed in Montana: indicate in which state licensed: _______________________________
Print Form
B.
INFORMED CONSENT/WAIVER OF REQUIREMENT OF BLOOD TEST FOR RUBELLA IMMUNITY
Important Information About the Need for Rubella Immunity Testing
Infection of a pregnant woman with the rubella virus in early pregnancy can be catastrophic to the unborn child.
Infection may lead to fetal death, spontaneous abortion, or premature delivery. If the fetus survives the
infection, the virus may affect any or all of its vital organs, and may cause a variety of congenital defects. Up to
85% of infants whose mothers are infected with the rubella virus in the first three months of pregnancy may
suffer significant health effects.
It is important that a woman be sure of her rubella immunity status prior to becoming pregnant because rubella
immunizations are not recommended for pregnant women. While a woman might believe that she has had
rubella in the past, and is now immune, many illnesses that cause a rash may mimic a rubella infection, so she
may have been diagnosed with rubella when she was not actually infected with the rubella virus. A woman
might also know or believe that she was immunized for rubella, but not everyone who is immunized has a
sufficient immune response from the immunization to confer lifelong immunity.
The only way to be certain of rubella immunity is to have a blood test to confirm the presence of rubella
antibodies. The results of the blood test will allow you to make appropriate decisions, in consultation with your
physician, regarding your rubella immunity status and possible need for rubella immunization prior to becoming
pregnant.
Applicants may obtain additional information regarding rubella and rubella immunity testing at their local county health
department or the Montana Department of Public Health & Human Services Immunization Program,
(406) 444-5580.
Reference:
Epidemiology and Prevention of Vaccine-Preventable Diseases, 10
th
Edition, January 2007. Edited by: William Atkinson,
Jennifer Hamborsky, Lynne McIntyre and Charles Wolfe, Chapter 12.
______ We request a waiver of the requirement for medical certification of blood testing for rubella immunity
(or medical exemption therefrom). We have read and we understand the information provided regarding the
importance of rubella immunity testing, and we accept full responsibility for any consequences that might arise
from our failure to obtain a blood test for rubella immunity prior to marriage.
We attest that we are the applicants for a marriage license for which this certification/informed consent is
required. By our signatures, we attest that we have both seen the results of the serological test for rubella
immunity or are medically exempt, or that we have both been informed of the importance of rubella immunity
testing but request a waiver of the requirement for premarital testing as stated above.
______________________________________________ ___________________________________
Signature of Female Applicant Name Printed
_______________________________________________ ____________________________________
Signature of Male Applicant Name Printed
_______________________________________________ ____________________________________
Signature of Clerk of District Court Date Received
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STATE OF MONTANA - PREMARITAL TESTING FOR RUBELLA (Rosebud County)

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Completed 25 January 2021

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