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
Requestee First Name:
* must provide value
Requestee Last Name:
* must provide value
Former Names and/or Aliases:
Date of Birth: * must provide value Gender: * must provide value
Date of Birth:
* must provide value
M-D-Y
Gender:
* must provide value
Male
Female
Other
Street Address: Street Address 2: City: Zip Code: State: * must provide complete address for verification
Street Address:
* must provide value
City:
* must provide value
Zip Code:
* must provide value
State:
* must provide value
Out Of Usa Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Is Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
If outside of the USA, please provide the country:
Requestor's Full Name: * must provide value Requestor's Relationship: * must provide value
Requestor's Full Name:
* must provide value
Requestor's Relationship:
* must provide value
Self Parent Legal Guardian Medical Provider Adult Caregiver Other
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
No match
Current E-mail:
* must provide value
Re-enter Email:
* must provide value
Current Phone Number:
* must provide value
How would you like to receive your vaccination record?
* must provide value
Email Fax Mail
If you would like to receive your record via a different method and not have it securely emailed, please specify:
* must provide value
Mail Fax
Mailing Address: Mailing Address 2: City: Zip Code: State: * must provide complete address for verification
Street Address:
* must provide value
City:
* must provide value
Zip Code:
* must provide value
State:
* must provide value
Out Of Usa Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Is Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
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
No
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
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: Month Day Year
Patient or Representative Signature Date Patient or Representative Printed Name Relationship to Patient (if signed by representative)
Patient Name
* must provide value
Date of Birth
* must provide value
Today M-D-Y
Social Security Number
* must provide value
Authorized Entity
* must provide value
Released to Name
* must provide value
Records to be Released
* must provide value
Information use purpose
* must provide value
Signature
* must provide value
Signature Date
* must provide value
Today M-D-Y
Printed Name
* must provide value
Please upload a copy of one of the following proof of identity:
Drivers license Photo ID Passport * must provide value
Supported file types include PDF and JPG with a size of 10KB or smaller. Please note that .HEIC images are not supported.
E-Signature:
* must provide value
Today M-D-Y