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ImmTrac2 Forms & Documents

Print single copies below or order in quantity by stock number from www.ImmunizeTexasOrderForm.com. ImmTrac2 brochures and posters may also be ordered from the link above. For assistance with ordering, please call the Immunization Unit at (800) 252-9152. 
Stock # Title
General/Miscellaneous Consent Forms: 
C-7 Immunization Registry (ImmTrac2) - Minor Consent Form (rev. 03/2017) 
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.
EF11-1366ARegistro de Vacunas (ImmTrac2) - Formulario de Consentimiento Para Adultos (rev. 03/2017)
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.
F11-12955ARegistro 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.
F11-12956ARegistro de Inmunización (ImmTrac2) - Formulario de Consentimiento de Retención de Información Sobre el Desastre (rev. 03/2017)
Request an 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. 
Newborn Consent Form:
F11-11936 ImmTrac2 Newborn Registration Form - Bilingual (rev. 03/2017)
Use this form to grant or deny newborn registration in ImmTrac2.
For use by birth registrars only.
ImmTrac Withdrawal Form:
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)

Documents for Providers & Payors:
Stock #Title
11-11445                                   Electronic Transfer Standards for Providers - Coming Soon

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 - Coming Soon
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. 

11-12222   ImmTrac2 Consent Guidelines for Providers - Coming Soon
E11-11402 Frequently Asked Questions (FAQs) for Healthcare Providers - Coming Soon
E11-12934New User Welcome Kit - Coming Soon 
E11-14181 ImmTrac2 Consent Withdrawal Process for Providers Who Affirm Consent - Coming Soon
E11-14182 Meaningful Use (HL7) Quick Guide - Coming Soon

General Fact Sheets:
  • What is ImmTrac2? - Coming Soon
  • Impact of HIPAA on reporting to ImmTrac2 - Coming Soon
  • Current Texas Law: Immunization Reporting & Consent Requirements - Coming Soon

Helpful Links:


 



Last updated August 30, 2017