Missouri department of health and senior services bureau of immunization assessment and assurance Save Print REQUEST FOR OFFICIAL STATE OF MISSOURI IMMUNIZATION RECORDS please complete this form by typing or printing all required fields - - 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter your first name, last name, date of birth (in month/day/year format), last four digits of your Social Security Number, and current address with telephone number. Ensure all fields marked with an asterisk (*) are completed.
3. Indicate your relationship to the client by selecting from options such as 'parent/guardian/custodian' or 'healthcare professional'.
4. In the 'Requestor Information' section, provide details such as school or childcare information, department client number (DCN) or Medicaid number, and your telephone number. Fill in your address and fax number if applicable.
5. Choose how you would like the immunization record sent to you: via email (encrypted for confidentiality) or US mail.
6. Sign the form where indicated and ensure that all required fields are filled out before submitting.

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