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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: ____________________

_________________

__________________

Last

First

Middle

Date of Birth: __________________

Sex: _____________

Race _____________

MM/DD/YYYY

Male or Female

Name of Parent or Guardian: _____________________

_______________

___________

Last

First

Middle

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

Date

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.

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