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Person or agency email address: ZIP Code: City: State: Address (number and street): Phone Number: Fax Number: Receiving agency or individual information. Send by: Fax _ Email _ Mail or Will pick up: Person or agency to receive records: AUTHORIZATION TO RELEASE IMMUNIZATION RECORDS/MyVaxIndiana PIN # Hamilton County Health Department Noblesville, IN 46060 Charles Harris, MD Health Officer INSTRUCTIONS: 1. Complete ALL portions of this form. A printed copy of record and MyVaxIndiana PIN # will be provided. 2. Reason for request of records: Returning for future vaccines? Yes: No: 3. Please sign and designate how you would like to receive records. 4. If you have any questions, please call the Hamilton County Health Department at [PHONE REDACTED]. Patient’s Name: (last name) (first name) (middle name) Date of Birth (month, day, year): Previous Name(s): Parent or Guardian (released to parent/guardian only if child under 18 years of age): Address (number and street): City: State: ZIP Code: Phone Number: I request and authorize the Hamilton County Health Department to release immunization information maintained in the Hamilton County Health Department Immunization/CHIRP database to the person or agency named below. Requested information will be provided to the designated person or agency listed below as soon as possible, but no later than ten (10) working days after receipt of this signed authorization. This authorization expires sixty (60) days after the date it is signed. A copy of this document is considered the same as the original. I further understand that I may revoke this authorization at any time be notifying the releasing organization in writing, but if I do it will not have any effect on any actions that were taken before my revocation is received. By signing this authorization, I acknowledge that I have read and understand this authorization. I understand that immunization records to be disclosed will be disclosed in accordance with this authorization. I declare under the penalty of perjury under the laws of the State of Indiana that the foregoing is true and correct, and that I am authorized to sign this release on the patient’s behalf. Signed on at (month/day/year) (city and state where signed) (signature of patient/parent or legal guardian if younger than 18 years) (relationship to patient) Notice: The Hamilton County Health Department keeps a record of immunizations that are entered into the Hamilton County or CHIRP Immunization Registry Program system by participating providers, health plans, vital records, and Medicaid. You may ask us for a copy of your record or your children's record. You may also ask us to correct that record. We will not disclose your record to others unless you direct us to do so, or unless the law authorizes or compels us to do so. To obtain your immunization record or PIN we recommend you first check with your provider's office. If they are unable to provide a copy of your complete immunization history, please contact the Hamilton County Health Department at [PHONE REDACTED]. For questions regarding MyVaxIndiana contact the CHIRP or MyVaxIndiana Help desk at 1-[PHONE REDACTED], or by email at: [EMAIL REDACTED] or [EMAIL REDACTED] Updated March 2024. SIGN