Lenawee County, MI · Lenawee County
Request for Official State of Michigan Immunization Record
This form lets an eligible person or requester ask for an official Michigan immunization record by providing identifying, contact, and relationship information.
At a glance
- Issued by
- City of Lenawee County · Lenawee County, Lenawee County, Michigan
- Notarization
- Not required: file this form without a notary.
- Official source
- lenawee.mi.us
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Use this form to request an official Michigan immunization record. It asks for the record holder’s identifying information and the requester’s name, relationship, address, telephone number, signature, and date. Requests must include a photocopy of the requester’s current state-issued driver’s license or picture ID; additional documentation is specified for social services agencies.
Who needs it
A person requesting their own record, an eligible requester for a child under 18, or a social services agency may use this form.
How to submit it
Fax the completed request to 517-335-9855 or mail it to Michigan Department of Health and Human Services-Immunization Program, PO Box 30195, Lansing, MI 48909. Allow 14 business days for processing.
About notarization
This request is signed and dated without a notary; include the required photocopy of the requester’s current state-issued ID, and agencies must also provide a formal request with a parent or guardian’s signature and ID copy.
How to submit this form
- 1
Download the Form
Download the official immunization record request form.
- 2
Complete the Request
Print clearly and provide the requested record-holder and requester information, then sign and date the form.
- 3
Gather Required Documents
Attach a photocopy of the requester’s current state-issued driver’s license or picture ID; social services agencies must follow the additional instructions on the form.
- 4
Send the Request
Fax the form to 517-335-9855 or mail it to the Michigan Department of Health and Human Services-Immunization Program in Lansing.
Frequently asked questions
- Do I need a notary for the immunization record request?
- No. Sign and date the request without a notary. Include a photocopy of your current state-issued driver’s license or picture ID; social services agencies have additional documentation requirements.
- How do I submit the immunization record request?
- Fax it to 517-335-9855 or mail it to the Michigan Department of Health and Human Services-Immunization Program, PO Box 30195, Lansing, MI 48909.
- What identification must accompany the request?
- Include a photocopy of the requester’s current state-issued driver’s license or picture ID. The form also lists extra requirements for requests from social services agencies.
- Who can request a record for someone under 18?
- The form asks the requester to state their relationship to the child. For a person 18 or older, only the person named on the immunization record may request a copy.