ImmTrac Forms and Documents

General/Miscellaneous Consent Forms:

ImmTrac - Immunization Registry Consent Form (rev. 05/2012)
Use this form to register your child, aged 17 and younger, in ImmTrac.
Birth registrars: DO NOT use this form. See F11-11936 below.

ImmTrac Adult Consent Form (rev. 05/2012)
Use this form to register as an adult (aged 18 and older) in ImmTrac.

ImmTrac First Responder/First Responder Family Member Consent Form (rev. 05/2012)
Use this form to register as a first responder and first responder family members, aged 18 and older.

ImmTrac Disaster Information Retention Consent Form (rev. 05/2012)
Use this form to retain your disaster-related information beyond 5 years.

Request an Immunization Record:

Authorization to Release ImmTrac History Form (rev. 04/2012)
Use this form to authorize release of your or your child's ImmTrac records.

Newborn Consent Form:

ImmTrac Newborn Registration Form (rev. 04/2014)
Use this form to grant or deny newborn registration in ImmTrac.
For use by birth registrars only.

ImmTrac Withdrawal Form:

Withdrawal of Consent and Confirmation Form (rev. 04/2014)
Use this form to withdraw your child or yourself from participation in ImmTrac.

Forms for Providers & Payors:

ImmTrac Site Registration Packet - Alternate, Paper Method (rev. 04/2014)
ImmTrac Site Agreement and Confidentiality Statement Renewal Packet - Alternate, Paper Method (rev. 05/2013)

Documents for Providers & Payors:

Providers:

New User Welcome Kit (rev. 04/2014)
ImmTrac User Instructional Manual (rev. 06/2011)
Electronic Transfer Standards for Providers (rev. 02/2013) - Use this document only if you are a Provider. If you need information for payors, contact ImmTrac Customer Support at (800) 252-9152 or by e-mail.
ImmTrac Consent Guidelines for Providers (rev. 03/2012)
Frequently Asked Questions (FAQs) for Health-care Providers (rev 04/2014)
ImmTrac Consent Withdrawal Process for Providers Who Affirm Consent (rev. 11/2008)
Meaningful Use (HL7) Documents
Meaningful Use (HL7) Quick Guide (rev. 03/2014)

Payors:

Payor Information (rev. 10/2010)

General Fact Sheets:

What is ImmTrac? (rev. 03/2012)
Impact of HIPAA on reporting to ImmTrac (rev. 09/2011)
Current Texas Law: Immunization Reporting & Consent Requirements (rev. 03/2012)

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