DECLINE OR START SHARING/INFORMATION REQUEST FORM

PLEASE CHOOSE THE STATEMENT(S) BELOW THAT APPLY:

MY FULL NAME:

RELATIONSHIP TO PATIENT

Self Parent/Guardian

Name of Patient:

Patient Date of Birth:

Patient’s Street Address:

Patient’s City/Zip Code:

Patient County:

Patient ID (optional):

Patient Phone:

DECLINE SHARING

I DECLINE to allow my/my child’s immunization/ tuberculosis (TB) screening test record to be shared with other health care providers, agencies, or schools in the California Immunization Registry (CAIR).*

Note: The immunization record/TB Tests may still be recorded in the registry for use by your physician’s office. By law, public health officials can also access immunization/TB test records in the case of a public health emergency.

START SHARING

(Declined earlier, now have changed mind and wish to share.)

I ALLOW my/my child’s immunization/TB test record to be shared with other health care providers, agencies, or schools in CAIR.

REQUEST INFORMATION

I REQUEST a list of agencies who have viewed my/my child’s CAIR immunization/TB test record.

I REQUEST to review or correct my/my child’s CAIR immunization/TB test record. I understand that any changes made to this record must be verified by appropriate documentation from my health care provider.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Fax or email this form to the CAIR Help Desk at 1-888-436-8320, CAIRHelpDesk@cdph.ca.gov

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