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The Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS). The Texas Immunization Registry is a secure and confidential service that consolidates and stores your child’s (younger than 18 years of age) immunization records. With your consent, your child’s immunization information will be included in the Texas Immunization Registry. Doctors, public health departments, schools, and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed. For more information, see Texas Health and Safety Code Sec. 161.007 (d). https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.007. Consent for Registration of Child and Release of Immunization Records to Authorized Persons/Entities I understand that, by granting the consent below, I am authorizing release of the child’s immunization information to DSHS and I further understand that DSHS will include this information in the Texas Immunization Registry. Once in the Texas Immunization Registry, the child’s immunization information may by law be accessed by a public health district or local health department, for public health purposes within their areas of jurisdiction, a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient, a state agency having legal custody of the child, a Texas school or child-care facility in which the child is enrolled, and a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may withdraw this consent at any time by submitting a completed Withdrawal of Consent Form in writing to the Texas Department of State Health Services, Texas Immunization Registry. State law permits the inclusion of immunization records for First Responders and their immediate family members in the Texas Immunization Registry. A “First Responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An “immediate family member” is defined as a parent, spouse, child, or sibling who resides in the same household as the First Responder. For more information, see Texas Health and Safety Code Sec. 161.00705. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.00705.
Please mark the box below to indicate whether your child is an Immediate Family Member of a First Responder.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas Immunization Registry. Parent, legal guardian, or managing conservator:
Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See https://www.dshs.texas.gov/ for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004) Upon completion, please fax or mail form to the DSHS ImmTrac2 Group or a registered Health-care provider. Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com Texas Department of State Health Services • ImmTrac2 Group – MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347 PROVIDERS REGISTERED WITH ImmTrac2: Please enter client information in ImmTrac2 and affirm that consent has been granted. DO NOT fax to ImmTrac2. Retain this form in your client’s record.
The Texas Immunization Registry (ImmTrac2) has been designated as the disaster-related reporting and tracking system for immunizations, antivirals, and other medications administered to individuals in preparation for, or in response to, a disaster or public health emergency. From the time the event is declared over, the Texas Immunization Registry will retain disaster-related information received from health-care providers for a period of five (5) years. At the end of the five (5) year retention period, client-specific disaster-related information will be removed from the Texas Immunization Registry unless consent is granted to retain the client information in the Texas Immunization Registry beyond the five (5) year retention period. For more information, see Texas Health and Safety Code Sec. 161.00705. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.00705. Consent for Retention of Disaster-Related Information and Release of Information to Authorized Entities I understand that, by granting the consent below, I am authorizing retention of my (or my child’s) disaster-related information by DSHS beyond the five (5) year retention period. I further understand that DSHS will include this information in the Texas Immunization Registry. Once in the Texas Immunization Registry, my (or my child’s) disaster-related information may by law be accessed by: a state agency, for the purpose of aiding and coordinating communicable disease prevention and control efforts, and/or a physician or other health-care provider legally authorized to administer immunizations, antivirals, and other medications, for treating the client as a patient; I understand that I may withdraw this consent to retain information in the Texas Immunization Registry beyond the five (5) year retention period and my consent to release information from the Texas Immunization Registry, at any time by written communication to the Texas Department of State Health Services.
State law permits the inclusion of immunization records for First Responders and their immediate family members in the Texas Immunization Registry. A "First Responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An “immediate family member” is defined as a parent, spouse, child, or sibling who resides in the same household as the First Responder.
Please mark the appropriate box to indicate whether you are a First Responder or an Immediate Family Member.
By my signature below, I GRANT consent to retain my disaster-related information (or my child’s information, if younger than age 18) in the Texas Immunization Registry beyond the 5 year retention period. Client (or parent, legal guardian, or managing conservator:)
A record of all children 18 years of age or younger who receive immunizations through the Texas Vaccines for Children (TVFC) Program must be kept in the health care provider’s office for a minimum of five (5) years. The record may be completed by the parent, guardian, individual of record, or by the health care provider. TVFC eligibility screening and documentation of eligibility status must take place with each immunization visit to ensure eligibility status for the program. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccines under the TVFC Program.
1. Child's Name:
2. Child’s Date of Birth:
3. Parent, Guardian, or Individual of Record:
4. Primary Provider’s Name:
5. To determine if a child (0 through 18 years of age) is eligible to receive federal vaccine through the TVFC Program, at each immunization encounter or visit, enter the date and mark the appropriate eligibility category.
Eligible for VFC Vaccine
State Eligible
Not Eligible
State Eligible Test
* Underinsured includes children with health insurance that does not include vaccines or only covers specific vaccine types. Children are only eligible for vaccines that are not covered by insurance. In addition, to receive VFC vaccine, underinsured children must be vaccinated through a Federally Qualified Health Center (FQHC), a Rural Health Clinic (RHC), or under an approved deputized provider. The deputized provider must have a written agreement with an FQHC or an RHC and the state, local, or territorial immunization program in order to vaccinate underinsured children. ** Other underinsured are children that are underinsured but are not eligible to receive federal vaccine through the TVFC Program because the provider or facility is not an FQHC or an RHC, or a deputized provider. However, these children may be served if vaccines are provided by the state program to cover these non-TVFC-eligible children. *** Children enrolled in the State of Texas Children’s Health Insurance Program (CHIP). An agreement between the DSHS Immunization Unit and CHIP stipulates that vaccines for eligible CHIP enrollees are purchased through the federal contract.
Please sign electronically below.
You have signed this document electronically. You hereby confirm that you are consent to signing this document electronically.
