DECLINE OR START SHARING/INFORMATION REQUEST FORM

Please correct the errors described below.

PLEASE CHOOSE THE STATEMENT(S) BELOW THAT APPLY:

DECLINE SHARING

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.)

REQUEST INFORMATION

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.

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

Your message will be encrypted.