My Vax Records Demographic Immunization Record Amendment Request

NOTE: Before beginning this process, it may be faster to request any updates to your immunization record directly from your current healthcare provider or to​​​​ utilize our electronic amendment form request system to request the Massachusetts Department of Public Health (MDPH) make the demographic updates to your immunization record. You may access the electronic system at the following link: https://myvaxrecords.mass.gov/pages/Request. If that is not possible, please read this information and complete the form below: 

The Massachusetts Immunization Information System (MIIS) is a web-based system that keeps track of all immunizations healthcare providers administer to children and adults in Massachusetts.  The system was established in 2011 and is operated by the Massachusetts Department of Public Health (MDPH) according to state law (M.G.L c. 111, Section 24M).  

All individual information in the MIIS is kept confidential in accordance with applicable law.

To request a MDPH Demographic Immunization Record Amendment, please submit the following and allow up to 10 business days for processing:

•	Both pages of the Demographic Immunization Amendment Request Form, completed and signed
•	A photocopy of your driver’s license, or other state-issued ID, with the license number shielded or removed
•	If you are requesting a name change (not a minor misspelling), you must submit legal proof of name change
•	If your new address is not reflected on your ID, please submit proof of your new address (e.g. a copy of a utility bill)

MDPH cannot amend the demographic information associated with your MIIS immunization record without the documentation listed above. 

Please return the completed paperwork to MDPH by mail or fax: 

My Vax Records
Massachusetts Immunization Information System (MIIS)
Massachusetts Department of Public Health, Immunization Division
305 South Street, Jamaica Plain, MA 02130

FAX: 857-323-8321

DO NOT SUBMIT VIA EMAIL – MIIS EMAIL IS NOT SECURE

My Vax Records Demographic Immunization Record Amendment Request Form Page 1 of 2

Individual or Dependent Information: 

Information on Record being updated: This information is necessary to ensure the identity of the individual whose record is being updated (i.e. you, your child, or individual over whom you have legal authority). 

NAME: _____________________________________________________________________________________________________________________
     	LAST						FIRST					MIDDLE

DATE OF BIRTH: _ _/_ _/_ _ _ _	GENDER: __________________	PHONE NUMBER: _____________________________
	           MM/DD/YYYY	

ADDRESS: ________________________________________________________________________________________________________
	 STREET						CITY			STATE		ZIPCODE

MOTHERS MAIDEN NAME: _____________________________________________________
	         	       IF AVAILABLE FOR INDIVIDUAL YOUNGER THAN 18 YEARS OF AGE			

Information on Requestor of the record: This information is necessary to ensure the individual/agency has the legal authority to complete this record request. 

q Requestor same as above – skip to Signature of Requestor, otherwise complete section below.

NAME: __________________________________________________________________________________________________________________
               LAST				FIRST				MIDDLE

ADDRESS: ________________________________________________________________________________________________________
	 STREET				CITY			STATE			ZIPCODE

PHONE NUMBER: __________________

I authorize the Massachusetts Department of Public Health to release confirmation of record processing to the following:

Email: ________________________________________________________ 

If you do not have access to an email, you may request confirmation via Fax or Phone:

Fax: ____________________________

Phone: __________________________

SIGNATURE: _________________________________________________________________________   DATE: _________________
Signature of Requestor: I am requesting an update to the demographic information associated with my own record, or I am the parent, guardian, or other person legally authorized to act for the person whose record I am requesting.  I certify under the penalties of perjury that the information I am providing is true to the best of my knowledge.
My Vax Records Demographic Immunization Record Amendment Request Form Page 2 of 2

Description of requested change to demographic information in immunization record: 

Please explain what change you are requesting: