Massachusetts Immunization Information System (MIIS) forms

Forms for record requests, amendment request, record not found amendment request, and MIIS objection (or withdrawal of objection).

You can request to access your vaccination records online. The My Vax Records tool lets you access your COVID-19 digital vaccine card and your Massachusetts vaccination history from the MIIS: Access My Vax Records online.

If you are having trouble accessing your records through My Vax Records or found a discrepancy on your MDPH immunization record, you may submit an online record amendment request for MDPH to investigate the concern: Submit an online record amendment request.

If you are unable to use the online system, download and print the forms below to submit by mail or fax. The files are available in multiple languages and instructions on how to submit are included on each form.

Table of Contents

Immunization record request

If you are unable to use the online system, you may submit a Paper Immunization Record request to receive a paper copy of your immunization record in the MIIS by completing the form below. Note, these forms must be mailed or faxed.

Record amendment request

If you accessed your MDPH Immunization Record and found a discrepancy you may submit an online form for MDPH to investigate the issue at the following link: Online Record Amendment Request

If you're unable to use the online system, you may submit a Paper Record Amendment Request for  MDPH to investigate the concern. Note, these forms must be  mailed or faxed.

Clinical Immunization Amendment Request
Language PDF RTF
English MIIS Clinical Immunization Amendment Request (RTF)
Spanish MIIS Clinical Immunization Amendment Request - Spanish/español (RTF)

 

Demographic Amendment Request
Language PDF RTF
English MIIS Demographic Amendment Request (RTF)
Spanish MIIS Demographic Amendment Request - Spanish/español (RTF)

Record not found amendment request

If you attempted to use MyVaxRecords and received a “match was not found” message, you may submit an online form for MDPH to investigate the issue at the following link: Online Record Not Found Amendment Request

If you are unable to use the online system, you may submit a Paper Record Not Found Amendment Request  Note, these forms must be mailed or faxed.

Objection (or withdrawal of objection) form

The law requires that immunizations are reported to the MDPH through the MIIS. There is no option to “opt-out” of the MIIS. Your records will only be available to those involved in your or your child's care, who have a reason to know about them. The MIIS enables a new health care provider to check what shots you or your child have received in the past from other providers. If you prefer that you or your child’s immunization history not be shared in this way, you have the right to object to sharing your or your child’s immunization information.

If you object to data sharing, your or your child’s immunization information will still be in the MIIS, but only the provider(s) who administers your vaccines and the Department of Public Health will be able to see it. Please note: you will need to keep track of your or your child’s immunization records in the event that you change doctors or get immunizations from other health care providers.

To object to data sharing, you must complete the MIIS Objection (or Withdrawal of Objection) Form. If you change your mind, you can fill out the same form to have your or your child's immunization information shared in the MIIS.

If you have changed your mind or if you change your mind in the future and decide to share the information with more healthcare providers, you will need to Withdraw your previous objection to sharing your or your child’s immunization information.

To limit data sharing, please complete the form below. Note, these forms may only be mailed or faxed.

 

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