IDPH Immunization Record Request Form

Did you know? You may be able to immediately access your immunization records online through Vax Verify*: the online immunizations portal. Please visit the site to learn more and register: https://idphportal.illinois.gov/s/

*Vax Verify works by matching Experian Credit information to information in the Immunization Registry. Errors may occur if information does not exactly match or if there is a freeze on your credit report.

If you are unable to access your record in Vax Verify, please review our helpful hints before starting/submitting this online form:

Complete and sign* this PDF form for our records (it will need to be attached as part of your request): https://dph.illinois.gov/content/dam/soi/en/web/idph/forms/topics-services/prevention-wellness/immunization/i-care/I-Care_Release_12.13.21.pdf

*Signatures must be handwritten or be a verified electronic signature that includes a date/time stamp (via DocuSign, Adobe, etc.). Typed signatures will not be accepted.

If anyone other than the patient (18+) or the patient’s biological parents (for minors) is signing the form on the patient’s behalf, please also submit a court order proving guardianship (examples include patients who are wards of a state entity, patients whose guardian is a family member other than their biological parents, disabled adults with guardians, etc.).

*Please allow 3-4 weeks for processing.

*The immunization record we send you will not contain a QR code.

*IDPH is not able to replace a COVID vaccination card: the immunization record you will receive from us will list all immunizations we have on file for you in I-CARE.

Today's Date*

Patient First Name*

Patient Last Name*

Patient Middle Initial

Patient Date of Birth*

month/date/year

Who is requesting the record?*

Patient

Patient's Parent or Legal Guardian (if patient is under 18 years old)

Guardian or Medical Power of Attorney

Patient Request

The patient will sign the PDF request form (see attachment instruction at the bottom of this page).

Please sign your full legal name legibly.
Electronic (typed) signatures can only be accepted if accompanied by a date/time stamp from a verified signature program (Adobe Sign, DocuSign, etc).

Parent/Guardian Request of patient under 18 years old

The parent/guardian will sign the PDF request form (see attachment instruction at the bottom of this page).

Please sign your full legal name legibly.
Electronic (typed) signatures can only be accepted if accompanied by a date/time stamp from a verified signature program (Adobe Sign, DocuSign, etc).

Guardian or Power of Attorney Request

This person will sign the PDF request form on behalf of the patient (see attachment instructions at the bottom of this page). Please be sure to attach legal documentation proving guardianship or POA status.

Please sign your full legal name legibly.
Electronic (typed) signatures can only be accepted if accompanied by a date/time stamp from a verified signature program (Adobe Sign, DocuSign, etc).

Name of Parent*

Name of Guardian or Medical Power of Attorney*

Patient, Parent, or Guardian's email*

Please provide your email address so that we may contact you if there are questions about the request.

Patient, Parent, or Guardian's phone*

Phone

Patient's current street address*

City*

State*

Zipcode*

Listing of patient's previous Illinois addresses

This will help us to identify you if your current address is not in the registry.

Listing of patient's previous names

We can only release records that match the names you report. If you have a different name (e.g., Maiden name, alias name, nick name, legal name change, etc.), please list them here.

Who is the patient's current health care organization?

If known, please provide the name of the office/organization where the patient receives regular immunizations.

Person/Agency/Facility to receive record

If you wish, we can send the requested record directly to agencies such as nursing homes, schools, Dr's offices, etc..

Choose method of delivery*

E-mail, Fax, or Mail *choose only ONE option, as we will not send it multiple ways

Select

Agency fax number*

Agency mailing address*

I understand that I need to complete the immunization record request form found on the IDPH website, sign, and upload to this sheet in order to receive my immunization record

File Upload*

Upload completed and signed IDPH Immunization Record Request Form. If you need to upload additional documentation (guardianship, legal name change) please upload here as well.

Please do not send copies of vaccination cards, immunization records, social security cards, driver's license, etc.

Drag and drop files here or

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