AUTHORIZATION TO RELEASE IMMUNIZATION RECORDS - Chirp - chirp in 2026

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The document is an authorization form for the release of immunization records from the Children and Hoosiers Immunization Registry Program (CHIRP) in Indiana. It requires completion of patient details, guardian information if applicable, and specifies how the records will be sent to a designated person or agency. The authorization is valid for 60 days and can be revoked at any time. It also includes instructions for submitting the form and contact information for support.

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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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2013	4 Satisfied (52 Votes)

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AUTHORIZATION TO RELEASE IMMUNIZATION RECORDS - Chirp - chirp in 2026

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