The Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS). The Texas Immunization Registry is a secure and confidential service that consolidates and stores your immunization records. With your consent, your immunization information will be included in the Texas Immunization Registry. Doctors, public health departments, schools, and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed. For more information, see Texas Health and Safety Code Sec. 161.007 (d). https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.007.
Consent for Registration and Release of Immunization Records to Authorized Persons / EntitiesI understand that, by granting the consent below, I am authorizing release of my immunization information to DSHS and I further understand that DSHS will include this information in the Texas Immunization Registry. Once in the Texas Immunization Registry, my immunization information may by law be accessed by: a Texas physician, or other health-care provider legally authorized to administer vaccines, for treatment of the individual as a patient; a Texas school in which the individual is enrolled; a Texas public health district or local health department, for public health purposes within their areas of jurisdiction; a state agency having legal custody of the individual; a payor, currently authorized by the Texas Department of Insurance to operate in Texas for immunization records relating to the specific individual covered under the payor’s policy. I understand that I may withdraw this consent at any time by submitting a completed Withdrawal of Consent Form in writing to the Texas Department of State Health Services, Texas Immunization Registry.
State law permits the inclusion of immunization records for First Responders and their immediate family members in the Texas Immunization Registry. A “First Responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An “immediate family member” is defined as a parent, spouse, child, or sibling who resides in the same household as the First Responder. For more information, see Texas Health and Safety Code Sec. 161.00705. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm This Vaccination Permission, Release, & Screening Consent Form for Adults has been adapted from the Screening Checklist for Contraindications to vaccines for Adults as published by Immunize.org https://www.immunize.org/catg.d/p4065.pdf, as well as the Texas Immunization Registry (ImmTrac2) Adult Consent Form Stock No. F11-13366 https://www.dshs.texas.gov/sites/default/files/immunize/immtrac/docs/F11-13366.pdf. The Other Guys Pharmacy, Inc provides this document for use by health-care professionals as a courtesy and makes no representation or warranties, express or implied, as to its suitability, legal effect, completeness, currentness, accuracy, and/or appropriateness. The Other Guys Pharmacy, INC. is not responsible for the information collected or the interpretation of the patient assessment. All health-care professionals choosing to use this form must consult business and legal advisors to determine the appropriateness of the form and make necessary changes or add any additional documentation required by pharmacy, or health-care SOPs or applicable law.
Privacy NotificationWith few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
PROVIDERS REGISTERED with the Texas Immunization RegistryPlease enter client information in the Texas Immunization Registry and affirm that consent has been granted. DO NOT fax to the Texas Immunization Registry. Retain this form in your client’s record.
This form is provided without any representations or warranties, express or implied, as to its suitability, legal effect, completeness, currentness, accuracy, and/or appropriateness. The form is provided “as is”, “as available”, and with “all faults”, and Health Mart Pharmacy, Inc., its affiliates, employees, officers and directors disclaim any warranties, including but not limited to the warranties of merchantability and fitness for a particular purpose. This form may be inappropriate for your particular circumstances. Additionally, applicable laws may require different or additional provisions to ensure the desired result. You should consult with legal counsel to determine the appropriate forms necessary to suit your needs, as this form is only a sample and may not be applicable to your particular situation.
