MIIC Record Update Request

If you are unable to access your Minnesota Immunization Information Connection (MIIC) immunization record through Docket , please fill out this form. The Minnesota Department of Health (MDH) will verify and update your immunization record, or the record for the person that you are the parent/guardian of, so that you can access the record using the Docket application.

Learn more about MIIC at MIIC and the Public.

MDH is collecting this data to allow you to access your immunization records, or the records for the person you are the parent/guardian of, using the Docket application. The Docket application allows a person to access their immunization record, or the record of a person they are the parent/guardian of through MIIC. The information you provide will be used to ensure your MIIC client information is up to date and accurate. Only MDH, your health care provider, and those authorized under law will have access to this information.

You are not legally required to provide this information, but if you do not provide the requested information, we will not be able to update the immunization record so that you can access it through the Docket application.

Once you have submitted your request, MDH will process the request within 14 business days. Requests will be processed in the order they are received. A confirmation email will be sent once the MIIC record has been updated.

This form is for people who are planning to access their records using the Docket application.

If you have any questions about MIIC record requests, please email Health.immrecords@state.mn.us.

I am submitting this request for:

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Myself

Person I am the parent/guardian of

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Self Certification

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I certify that I am submitting this form on behalf of myself to update my record. (It is against the law to submit this form on behalf of someone else.)

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Parent or Guardian Certification

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I certify that I am the parent or guardian of this person and I have the legal authority to request and update to their record. (If you are not the parent or guardian of this person, it is against the law to submit this form on behalf of this person.)

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First Name

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Last Name

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Middle Name

Former Name(s)/Nickname(s)

Date of Birth

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M-D-Y

Gender

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Mother's Maiden Name

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Current/Permanent Street Address

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City

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State

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Zip Code

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Former Address(es)

New Phone Number to be entered into MIIC

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Please enter your information below. If we cannot verify the MIIC record, we will call and/or email you to follow up with your request.

Requestor's First Name

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Requestor's Last Name

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Requestor Phone Number

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Requestor's Email

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Record in MIIC?

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Yes

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MIIC ID

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Phone Number Updated in MIIC?

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Yes

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Phone Request?

Yes

Request Status

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Confirmation Email Sent?

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Notes

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