Illinois' Immunization Registry Opt Out Of Registry Form - Department Of Public Health


Illinois’ Immunization Registry
Opt Out of Registry Form
This form is required to allow an individual to request that a person’s immunization history be removed from the
registry, and no further immunization data be accepted into the registry. Please print.
Name of Client: ____________________
Date of Birth: __________________
Sex: _____________
Race _____________
Male or Female
Name of Parent or Guardian: _____________________
Relation: ___________________ Telephone Number _________________________
Street Address: ____________________________________________________________
City: ____________________________ State: _________________ ZIP: ______________
I request this person be removed from the Illinois Immunization Registry. I understand the state will not share
immunization data on this person from the registry as a result of this action. The registry will retain core
demographic information necessary to identify the client has chosen to opt out of the registry. This information is
necessary to enable the registry to filter and refuse entry of immunization information for the client. Additionally,
any prior immunization records associated with the client will not be shared from the registry.
The completed opt out form will be maintained at the provider’s office in the patient file.
No immunization information will be added to the registry for this client until the Illinois Immunization Program
receives notification the individual, parent or legal guardian wishes to opt back into the registry. To opt back in,
check the box below and date. The provider is responsible for keeping this form as well as opting the patient back
into the Illinois Immunization Registry.
___________________________________________ __________________
Signature of Parent or Guardian
You have the right to change this decision at any time. If you refuse today, you can decide later if you
would like to participate by checking the box at the left. Please initial and date after box is checked.
Please place a copy in the patient’s medical chart, provide a copy to the parent.


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