Immunization Registry Information System (IRIS ... - Iowa

IRIS - Immunization Program

Immunization Registry Information System (IRIS)

Lucas State Office Bldg, 5th Floor 321 E 12th Street

Adult Record Request

Des Moines, IA 50319-0075 Phone: (800)374-3958

Fax: (800)831-6292



Email: irisenrollment@idph.

Iowa's Immunization Registry Information System (IRIS) is a statewide database of immunizations administered in Iowa from either public or private providers. IRIS helps parents, health care providers, schools and other authorized users to know an individual's immunization and health screening status.

Iowa state law [Iowa Code ? 22.7(2) and 641IAC Chapter 7] specifies immunization and health screening information is confidential, which can only be shared with enrolled users, including an individual's health care provider, school, child care facility, local health department, the individuals themselves.

Once an individual attains 18 years of age, that person's parents can no longer request a record, but the legal adult may request the information directly. To obtain a copy of your immunization or health screening record, please complete the following information and fax to the IRIS Help Desk at 800-831-6292.

First Name: Address: Previous/Maiden Name:

Middle:

Last:

City, State, Zip:

Date of Birth:

Gender: Female Male

Please send the record to one of the following:

Health Care Provider School

Myself

Other:

Recipient/to the attention of:

Name of Organization:

Fax Number: OR Mailing Address: OR Email:

Phone Number: City, State, Zip:

By signing this agreement, I verify the information listed above is true and accurate:

Print Name of Parent/Guardian:

Telephone Number:

Signature:

Date:

Office Use Only

Date Received: Record Not Sent Reason:

Record Found, Date Sent:

Initials: Initials:

Adult Record Request - August 2019

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download