Fillable TEXAS IMMUNIZATION MINOR (Please print clearly) For Clinic/Office (Collin County Government)

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TEXAS IMMUNIZATION MINOR (Please print clearly) For Clinic/Office (Collin County Government)

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BROWSE COLLIN COUNTY GOVERNMENT (TX) FORMS

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Child’s Last Name
Child’s First Name Child’s Middle Name
/
/
Child’s Date of Birth
Child’s Address Apartment # Telephone
City State Zip Code County
Mother’s First Name Mother’s Maiden Name
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 and stores your child’s (under 18 years of age) immunization
records. With your consent, your child’s immunization information will be included in ImmTrac. Doctors, public health departments,
schools and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed.
The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry.
Consent for Registration of Child and Release of Immunization Records to Authorized Entities
I understand that, by granting the consent below, I am authorizing release of the child’s 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, the
child’s immunization information may by law be accessed by:
• a public health district or local health department, for public health purposes within their areas of jurisdiction;
• a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient;
• a state agency having legal custody of the child;
• a Texas school or child-care facility in which the child is enrolled;
• a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child.
I understand that I may withdraw this consent to include information on my child in the ImmTrac Registry and my consent to release
information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group –
MC 1946, P.O. Box 149347, Austin, Texas 78714-9347.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas
immunization registry.
Parent, legal guardian or managing conservator: ________________________________________________________________________
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)
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. EC-7
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P.O. Box 149347 • Austin, TX 78714-9347 Revised 05/18/2012
TEXAS
DEPARTMENT OF STATE HEALTH SERVICES
IMMUNIZATION
REGISTRY (ImmTrac)
MINOR
CONSENT FORM
*Children under 18 years only.
For Clinic/Office Use
(Please print clearly)
Child’s Gender: Male Female
PROVIDERS REGISTERED WITH ImmTrac – Please enter client
information in ImmTrac and affirm that consent has been granted.
DO NOT fax to ImmTrac. Retain this form in your client’s record.
click to sign
signature
click to edit
(Favor de escribir claramente con letra de molde)
Apellido del Niño(a)
Nombre del Niño(a) Segundo Nombre del Niño(a)
/
/
Fecha de Nacimiento del Niño(a)
Dirección del Niño(a), Calle Apartamento # Teléfono
Ciudad Estado Código Postal Municipio
Nombre de la Madre Apellido de Soltera de la Madre
ImmTrac, el registro de inmunización de Texas, es un servicio gratis que proporciona el Departamento Estatal de Servicios de Salud de
Texas (DSHS). El registro de inmunización es un servicio seguro y confidencial que consolida y guarda el récord de inmunizaciones de
su niño(a) (menor de 18 años de edad). Con su consentimiento, la información de la inmunización de su niño(a) será incluida en
ImmTrac. Los doctores, departamentos de salud pública, escuelas y otros profesionales autorizados pueden tener acceso al historial de
inmunización de su niño(a) para asegurar que las vacunas importantes no le falten.
El Departamento Estatal de Servicios de Salud le anima a participar voluntariamente en el registro de inmunización de Texas.
Consentimiento Para Registrar al Menor y Dar a Conocer los Documentos de Inmunización a las Entidades Autorizadas
Entiendo que, con mi consentimiento a continuación, autorizo que se dé a conocer la información de inmunización del menor al DSHS, y
además entiendo que el DSHS incluirá esta información en el registro central de inmunización del estado (“ImmTrac”). Una vez que la
información del menor esté en ImmTrac, por ley la puede acceder:
• el distrito de salud pública o el departamento de salud local, para propósitos de salud pública dentro de sus áreas de jurisdicción;
• el médico, o algún otro médico o proveedor de atención de salud legalmente autorizado para administrar vacunas, en el
tratamiento del menor como paciente;
• la agencia estatal que tenga la custodia legal del menor;
• la escuela o la guardería de Texas en que el menor esté inscrito;
• el pagador, actualmente autorizado por el Departamento del Seguro de Texas para operar en Texas, con respecto a la cobertura del
menor.
Entiendo que puedo retirar este consentimiento para incluir información sobre el menor en el Registro de ImmTrac y mi consentimiento
para dar a conocer la información del registro en cualquier momento mediante comunicación escrita a Texas Department of State Health
Services, ImmTrac Group – MC 1946, P.O. Box 149347, Austin, Texas 78714-9347.
Al firmar abajo, YO AUTORIZO el consentimiento para registrarlo. Deseo INCLUIR la información de mi niño(a) en el registro
de inmunización de Texas.
Alguno de los padres, tutor legal o administrador de bienes: _______________________________________________________________
Escriba con letra de molde
_______________________ ______________________________________________________________________________________
Fecha Firma
Notificación Sobre Privacidad: Tan solo por unas cuantas excepciones, usted tiene el derecho de solicitar y de ser informado sobre la información que el Estado de Texas reúne sobre
usted. A usted se le debe conceder el derecho de recibir y revisar la información al requerirla. Usted también tiene el derecho de pedir que la agencia estatal corrija cualquier información
que se ha determinado sea incorrecta. Diríjase a http://www.dshs.state.tx.us para más información sobre la Notificación sobre privacidad. (Referencia: Government Code, 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. EC-7
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P.O. Box 149347 • Austin, TX 78714-9347 Revised 05/18/2012
*Solamente niños menores de 18 años.
For Clinic/Office Use
Género: Masculino Femenino
DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS
REGISTRO DE INMUNIZACIÓN (ImmTrac)
FORMULARIO DE CONSENTIMIENTO PARA MENORES
PROVIDERS REGISTERED WITH ImmTrac – Please enter client
information in ImmTrac and affirm that consent has been granted.
DO NOT fax to ImmTrac. Retain this form in your client’s record.
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Completed 13 February 2021

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