Authorization to release immunization records state form 52665 (r / 7-13) indiana state department of health, immunization program children and hoosiers immunization registry program (chirp) instructions: 1. complete all portions of this form. 2....
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9/1/2011 new york state department of health new york state immunization information system nysiis user agreement part 1: purpose this agreement represents a commitment by the authorized user to abide by the terms of public health law, title 6,...
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Carroll county public schools authorization for release of immunization records for admission to school individual submitting the authorization (parent or guardian of student) last name: street address: city: student name: first name: m.i.: apt....
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For office use only temp pin: a copy of this completed original document is considered the same as the originalauthorization to release immunization recordswashington state immunization information system, po box 47843, olympia, wa 985047843...
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All new students must return form completed. physicians signature is mandatory. returning students need only to update records. cortland christian academy immunization records last name first middle birthdate sex home address telephone school...
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John jay college form ho.004 office: student development department: health contact: 212.237.8052 last modified: immunization records form immunization records are required at least one week prior to registration. please complete this form or...
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Office of the state controllerstate mandated costs claiming instructions no. 200318immunization records: hepatitis boctober 6, 2003revised july 1, 2013in accordance with government code (gc) sections 17560 and 17561, eligible claimants maysubmit...
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Information on the i-care registry what is i-care? the illinois comprehensive automated immunization registry exchange (i-care) is an immunization registry developed and managed by the illinois department of public health. immunization registries...
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Connors state college immunization record name: ss #: to be completed and signed by your health care provider or attach copies of records. all information must be in english. required (mandatory) immunization for college students: two doses of...
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Office of the state controllerstate mandated cost claiming instructions no. 200915immunization recordsrevised july 1, 2015in accordance with government code (gc) sections 17560 and 17561, eligible claimants maysubmit claims to the state...
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Eed will n s, you ble to usci be a ay onal s from rrival lity. you m lect additi on, od a ligibi ti ol ho re forma d to c child n for delines fo may nee r more in actio e gui fo ou th ferred scis. ote: y of de you meet encies. n uest to u n g eq...
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Fort lewis college student health center release of immunization records colorado state law requires all collegebound students to present evidence of 2 mmr (measles, mumps, & rubella) vaccinations prior to starting college. to comply with colorado...
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Estrella pediatrics, p.c. 9305 w. thomas road, suite 125 phoenix, az 85037 telephone (623) 3883216 fax (623) 3884902 medical records fax (623) 2257967 authorization to release immunization record patient name: date of birth: print patient last...
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Alert iis 800 ne oregon street, suite 370 portland, oregon 97232 phone: (800) 980-9431 fax: (971) 673-0276 web: .alertiis.org email: alertiis state.or.us alert immunization information system (iis) request for sealing of adult record / purging of...
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Suny college of technology 10 upper college drive alfred, new york 14802 request for immunizations or health form student health services alfred: (607) 587-4200 fax: (607) 587-4203 wellsville: (607) 587-3141 fax: (607) 587-3198 i, (print name)...
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