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AUTHORIZATION TO RELEASE IMMUNIZATION RECORDS - Chirp - chirp in 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's name, including last, first, and middle names in the designated fields.
- Fill in the date of birth using the format month, day, year.
- If applicable, provide any previous names of the patient.
- For patients under eighteen, enter the parent or guardian's name and their contact information including address and telephone number.
- In the receiving agency information section, specify who will receive the records along with their fax number, telephone number, and email address.
- Sign and date the authorization at the bottom of the form. Ensure that you include your relationship to the patient if signing on their behalf.
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| Versions | Form popularity | Fillable & printable |
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| 2013 | 4 Satisfied (52 Votes) |
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chirp in gov
What is the requirement for schools to use CHIRP? Indiana Code requires schools to report immunization data in CHIRP by the first Friday of February each year.Read more
AUTHORIZATION TO RELEASE IMMUNIZATION RECORDS. State Form 52665 (5-06). Indiana State Children and Hoosiers Immunization Registry Program (CHIRP)Read more