F11 11406 2026

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The document is an authorization form from the Texas Department of State Health Services for clients to request the release of their official immunization history from the Texas Immunization Registry (ImmTrac). It includes sections for client information, requestor details, and options for how to receive the immunization record. Additionally, it provides privacy notification rights regarding personal information collected by the state.

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Click ‘Get Form’ to open the f11 11406 in the editor.
Begin by entering the client's name in the designated fields: Last, First, and Middle. Ensure accuracy for proper identification.
Fill in the Date of Birth section by selecting the Month, Day, and Year. Indicate the client's gender by checking either Male or Female.
Provide the client's address, including Street, City, State, and Zip code. This information is crucial for record delivery.
Specify how and where to send the official immunization record by filling out the Name/Organization and Address sections.
Complete the Requestor Information section fully. This includes printing your name (or that of a guardian), address, email (if available), and phone number.
Sign and date the form at the bottom to authorize release of records. Ensure all fields are filled before submission.

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