The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

UfAHc5XXWdPrHafvuJHCXgWqeQ8RgJTDBZR4vXKrePoRgEJ2BYH

MIIC Public Inquiry Form

The Minnesota Immunization Information Connection (MIIC) is a statewide immunization information system that stores electronic immunization records. MIIC combines immunizations a person has received into a single record, even if they were given by different health care providers in the state. MIIC helps Minnesotans stay up to date with their vaccines.

The information in MIIC is classified as private, and only those authorized by law (Minnesota Statutes, Section 144.3351) can access it.

Complete the following form to:

1. Request updates to a MIIC record.

2. Request to update privacy settings of a MIIC record. For more information on these settings, visit Data Privacy and MIIC Records.

3. Request a copy of a MIIC immunization record.

This form is for public requests only. Health care providers and/or individuals providing services should email the MIIC Help Desk at health.miichelp@state.mn.us.

Once you submit your request, MDH will process it within 14 business days. Requests will be processed in the order they are received. A confirmation email will be sent once the request has been completed. If you have any questions email health.immrecords@state.mn.us.

I am making this request as

* must provide value

Self

Parent/guardian

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Certification/Acknowledgement

It is against the law to submit this form on behalf of someone else that you do not have the legal authority to make this request.

If you are a licensed social worker who is completing this form as part of your job, stop and contact the MIIC Help Desk at health.miichelp@state.mn.us

* must provide value

I certify that I am submitting this form on behalf of myself; or as the parent or guardian of the person for whom I'm requesting information.

First name

* must provide value

Last name

* must provide value

Email address

* must provide value

Phone number

Request type

*Please note that the option "Request to update demographics" allows you to update demographic information to access MIIC records using Docket®.

* must provide value

First name

* must provide value

Middle name

Last name

* must provide value

Date of birth

* must provide value

M-D-Y

Gender

* must provide value

Mother's Maiden Name

Race

Ethnicity

Current street address

* must provide value

City

* must provide value

State

* must provide value

Zip code

* must provide value

Phone number

Former/alternate/other first name(s)

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Former last name(s)

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Previous addresses

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Record request

Provide the information below to request your or the person you are the parent/guardian of MIIC immunization record. This form is for public requests only. Health care providers should email the MIIC Help Desk at health.miichelp@state.mn.us for access to patient records.

Do you already have access to you or your family's MIIC records in Docket? Did you know that you can download a PDF copy of your MIIC record using Docket? For more information visit Docket and MIIC Immunization Records.

How do you want this record sent?

* must provide value

Encrypted email

USPS mail

Fax

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* must provide value

Mailing street address

* must provide value

City

* must provide value

State

* must provide value

Zip code

* must provide value

Fax

* must provide value

Who are we sending the request to?

This only needs to be filled out if the person receiving the records is different from the requestor

I would like to update the privacy settings of this MIIC record to:

* must provide value

Opt-out and seal the MIIC record. All Immunization and demographic information is kept on file and if additional information is reported, the records will continue to be updated. However, the information will not be released to any authorized user without your consent.

Opt-out and purge the MIIC record. When a record is purged, all immunization data is deleted, and no information is released to any authorized user. However, certain demographic details must be retained to prevent new immunization data from being added. Recovering information from a purged record is impossible.

Limit access to the MIIC record to the specific health care facility.

Opt-back into MIIC. The MIIC record will be available to all authorized users who are providing services to the individual.

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Name of organization

* must provide value

Address of organization

* must provide value

I would like to update the status of receiving MIIC-based immunization reminders for this MIIC record.

* must provide value

Has it been at least 7 days since vaccination date for all the immunizations you want entered into MIIC?

* must provide value

Yes

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How would you like to send the proof of vaccination?

* must provide value

Upload

Mail

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Upload immunization record

* must provide value

Upload file

When mailing or faxing the proof of immunization to MIIC, please include the "Request ID" that will be provided once you submit this form.

Mailing Address:

Minnesota Department of Health
MIIC Operations
P.O. Box 64975
St. Paul, MN 55164-0975

Fax Number:

877-771-6182

Upload record mailed by client

Upload file

Phone request

Yes

MIIC ID

Immunizations on record

Yes

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Request status

Notes

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

MIIC Public Inquiry Form

Requestor information

Demographic/contact information

Additional demographic information

Record request

Privacy setting change request

Immunization record update request

Record mailed by client (MDH staff only)

Internal processing (MDH staff only)

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