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 - To request an immunization record, click HERE.
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. Click here (PDF).
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. Click here (PDF).
Provider Enrollment Form - To access ImmuNet by Authorized users click here (PDF)
Medical Release for Opt-Out Client - Providers can request immunization records of Opt-Out clients with this form. Click here (PDF ).
Please visit our contact us page located here.
201 W. Preston Street, Baltimore, MD 21201-2399
(410) 767-6500 or 1-877-463-3464