Please mail or fax the completed form. Do not email the completed form as it places you at risk for exposing your sensitive information. Emailed forms will not be accepted unless you are able to use a secure email service.
Immunization Records Request form - Use this form to request immunization records for yourself or your dependent(s).
Opt-Out form - Parents and guardians should be notified before their children’s records are entered into ImmuNet. Please use this form if parents or guardians do not wish to share their child’s immunization record with providers in ImmuNet.
Rescind Opt-Out form - You can also change your mind and allow your/your child’s records made available to your/your child’s provider(s) by submitting this form.
Provider Enrollment Form - Use this form to request access to ImmuNet by Authorized users.
Medical Release for Opt-Out Client - Providers can request immunization records of Opt-Out clients with this form.
Please visit our contact us page located here.
201 W. Preston Street, Baltimore, MD 21201-2399
(410) 767-6500 or 1-877-463-3464