Record Not Found in My Vax Records Patient Portal

NOTE: Before beginning this process, it may be faster to request that your healthcare provider investigate your unfound immunization record or to​​​​ utilize our electronic amendment form request system to submit a request for the Massachusetts Department of Public Health (MDPH) to further investigate your unfound vaccination 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:

•	A Record Not Found in My Vax Records Patient Portal Form, completed and signed (page 1 of Record Not Found in My Vax Records Patient Portal) A completed Demographic Identify Verification Form (page 2 of Record Not Found in My Vax Records Patient Portal)
•	A photocopy of your driver’s license, or other state-issued ID, with the license number shielded or removed
•	If you have experienced a name change in the last 10 years, please submit proof of legal 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)

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

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 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

Demographic Identity Verification Form

Please complete as much of the following information as possible. MDPH will utilize this information to attempt to find your record. You may skip any questions that are not relevant for you. 

Current address: ____________________________________________________________________________
__________________________________________________________________________________________

Former two addresses: ______________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________

Former name (if applicable): ___________________________________________________________________

Current phone: ______________________________________________________________________________

Former phone numbers (list any you can remember): ________________________________________________

Current email address: _______________________________________________________________________

Former email address: ________________________________________________________________________

Last Vaccine Received: _______________________________________________________________________
Date Administered: ____________________________________________________________________
Administering Site: ____________________________________________________________________	

Primary Care Provider:	_______________________________________________________________________

Primary Care Facility:	_______________________________________________________________________