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Tennessee Immunization Information System Record Request Form

For individuals seeking a copy of your vaccination record, it is recommended that you request the records from the healthcare provider that vaccinated you.

1. Requestee Information: Enter identifying information including name and current address in order to associate the appropriate record in the statewide Tennessee Immunization Information System (TennIIS).

2. Authorization for Release of Protected Health Information: Please download, sign, and upload the below document.

3. Proof of Identity: All immunization record requests must be accompanied by document(s) that identify the person requesting the immunization record. Examples of acceptable forms of identification include: a driver's license, photo ID, or a U.S./Foreign passport or passport card with a photo. Please ensure the copy of identification submitted is unexpired and legible.

Alternatively, a request for a mailed copy of vaccination records may be submitted through this web portal. Records will be mailed to the address of record for the person who was vaccinated (in general, the address provided to the healthcare provider who administered the vaccine).

**If the record being requested is for an adult 18 years of age or older the request form must be completed and returned by the individual.**

Response Time: Due to a heavy volume of requests, there may be delays in receiving the records. Persons unable to obtain the records through this system (for example, those with a recent change of address) may visit their county health department during regular business hours to request the records.

Please note: This form is generally the quickest way to receive your records from our state office, however if you are unable to submit this form please contact the TennIIS Help Desk at 800-342-1813 Option 1.

Requesting an Immunization Record For:

First Name:	Middle Name:	Last Name:

* must provide value		* must provide value

Former Names/Aliases:

Date of Birth:
* must provide value
Gender:
* must provide value

Street Address:
Street Address 2:
City:
Zip Code:
State:
* must provide complete address for verification

If outside of the USA, please provide the country:

Requestor Information:

Requestor's Full Name:
* must provide value
Requestor's Relationship:
* must provide value

Please Specify "Other":

* must provide value

Current Phone Number:
* must provide value
Current Email:
* must provide value
Verify Email:
* must provide value

The email addresses entered do not match. Please verify that the email addresses entered are correct to proceed.

* must provide value

reset

How would you like to receive your vaccination record?

* must provide value

By completing the below Authorization for Release of Protected Health Information, your immunization record can be securely emailed to the email provided.

Would you like to receive the immunization record requested via secure email?

* must provide value

Yes No

reset

If you would like to receive your record via a different method and not have it securely emailed, please specify:

* must provide value

Mailing Address:
Mailing Address 2:
City:
Zip Code:
State:
* must provide complete address for verification

If outside of the USA, please provide the country:

Fax Number:

* must provide value

Authorization For Release of Protected Health Information

Are you completing this form on a mobile device such as a smartphone?

* must provide value

Yes

reset

Please fill out the following Authorization for Release of Protected Health Information form. To attach, print to PDF and upload in the field below.

Please upload your completed and signed Authorization for Release of Protected Health Information form:

* must provide value

Upload file

Please fill out the following Authorization for Release of Protected Health Information form:

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

TENNESSEE DEPARTMENT OF HEALTH

Patient Name:	Date of Birth:	Social Security Number:

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:

In accordance with Tennessee state law and the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:

Signing this authorization is a voluntary act. My treatment, payment, enrollment in a health plan, or eligibility
for benefits will not be conditioned upon my authorization of this disclosure.
Information disclosed under this authorization may be re-disclosed by the recipient, and this re-disclosure may no longer be protected by federal or state law.
I have the right to revoke this authorization at any time by writing to the county health department listed
below. I understand that revoking this authorization will not affect disclosures made or actions taken before
the revocation is received.
A copy of this authorization may be utilized with the same effectiveness as an original.

Name of the entity authorized to release information:

Information is to be released to:

Name	Address

Records authorized to be released: (Check all that apply, records not checked will not be released.)

This information will be used for the purpose of:

If no expiration date is specified below, this authorization will expire within one year of signature.

This authorization will expire on:
This authorization will expire on:	Month	Day	Year


Patient or Representative Signature	Date


Patient or Representative Printed Name	Relationship to Patient (if signed by representative)

Please upload a copy of one of the following proof of identity:

Drivers license
Photo ID
Passport

* must provide value

Upload file

* must provide value

This is to certify that I am the parent, guardian, custodian, or other such person in parental relationship to the child listed above, or the individual to whom the immunization record relates. I understand that all information submitted to the Tennessee Immunization Information System (TennIIS) is kept confidential in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

E-Signature:

* must provide value

Add signature

Date Completed:

M-D-Y

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

The email addresses entered do not match. Please verify that the email addresses entered are correct to proceed.

Please fill out the following Authorization for Release of Protected Health Information form:

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

TENNESSEE DEPARTMENT OF HEALTH

Drivers license

Photo ID

Passport

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