Forms and Documents

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Find the Document You're Looking for:

Forms for the General Public

  • Consent Forms for the Public – Minors and Adults
  • Immunization Record Request
  • Withdrawal Form

First Responders

  • Consent Form for First Responders and Family Members
  • Disaster Information Retention Form

Providers and Organizations

  • Newborn Registration Form
  • Manuals for Providers and Organizations


Print or order in quantity at www.ImmunizeTexasOrderForm.com. For assistance, call the Immunization Unit at (800) 252-9152. 

ImmTrac2 Forms & Documents

table-1
Stock #           Title
Consent Forms for Minors and Adults:
C-7
Immunization Registry (ImmTrac2) - Minor Consent Form (rev. 09/2017) 
Use this form to register your child, aged 17 and younger, in ImmTrac2.
Birth registrars: DO NOT use this form. See F11-11936 below.

C-7A
Registro de Inmunización (ImmTrac2) - Formulario de Consentimiento Para Menores (rev. 03/2017)
EF11-13366            
Immunization Registry (ImmTrac2) - Adult Consent Form - (rev. 03/2017)
Use this form to register as an adult (aged 18 and older) in ImmTrac2.
EF11-1366A
Registro de Vacunas (ImmTrac2) - Formulario de Consentimiento Para Adultos (rev. 03/2017)
Request and Immunization Record:
F11-11406 
Immunization Registry (ImmTrac2) Authorization to Release Official Immunization History (rev. 03/2017)
Use this form to authorize the release of your or your child's ImmTrac2 records.
 ImmTrac2 Withdrawal Forms:
C-8
Immunization Registry (ImmTrac2) - Withdrawal of Consent and Confirmation Form (rev. 03/2017)
Use this form to withdraw your child or yourself from participation in ImmTrac2. 
C-8A
Registro de Inmunización (ImmTrac2) - Retiro de Consentimiento y Confirmación (rev. 03/2017)



table-2
Stock #            
Title
F11-12955
Immunization Registry (ImmTrac2) First Responder/First Responder Family Member Consent Form (rev. 03/2017)
Use this form to register as a first responder and first responder family members, aged 18 and older.
F11-12955A
Registro de Inmunización (ImmTrac2) - Formulario de Solicitud de Personal de Primera Respuesta / Un Familiar (rev. 03/2017)
F11-12956
Immunization Registry (ImmTrac2) Disaster Information Retention Consent Form (rev. 03/2017)
Use this form to retain your disaster-related information beyond 5 years.
F11-12956A
Registro de Inmunización (ImmTrac2) - Formulario de Consentimiento de Retención de Información Sobre el Desastre (rev. 03/2017)


table-3
Stock #          
Title
Newborn Consent Form:
F11-11936ImmTrac2 Newborn Registration Form - Bilingual (rev. 03/2017)
Use this form to grant or deny newborn registration in ImmTrac2.
For use by birth registrars only.
 
Manuals:
11-14955
ImmTrac2: Texas Immunization Registry User Manual (rev. 03/2017)
The ImmTrac2 User Manual provides information on the new system and  how to navigate through the system.
11-14972
ImmTrac2 Implementation Guide for Immunization Messaging: HL7 Version 2.5.1 (rev. 01/2017)
The Implementation Guide provides specifications, standards, and examples for creating HL7 2.5.1 messages for data submissions for ImmTrac2. 
11-14977
ImmTrac2 Provider Online Enrollment Manual (rev. 02/2017)
The Provider Online Enrollment Manual provides information on the ImmTrac2 registration and renewal processes.
Coming Soon:
11-11445
Electronic Transfer Standards for Providers
Use this document only if you are a Provider. If you need information for payors, contact ImmTrac2 Customer Support at (800) 252-9152 or e-mail ImmTrac2@dshs.texas.gov
11-12158 
Payor Information
11-12222  
ImmTrac2 Consent Guidelines for Providers
E11-11402
Frequently Asked Questions (FAQs) for Healthcare Providers
E11-12934
New User Welcome Kit
E11-14181
ImmTrac2 Consent Withdrawal Process for Providers Who Affirm Consent
E11-14182
Meaningful Use (HL7) Quick Guide



 



Last updated December 21, 2017