Secure Patient Form

Secure Patient Form

This HIPAA Complaint form is the preferred method for existing Vermont Immunization Registry (IMR) users to send Protected Health Information to the Registry Team
This form is intended only for use by medical professionals as well as school and licensed child care that have already applied for access to the Vermont Immunization Registry
It looks like this requires action on your part. Please click on the appropriate agreement below to gain access to the Registry.
- Health Care and Licensed Child Care Provider Confidentiality Agreement
- School User Confidentiality Agreement
This form is only intended for medical professionals. Members of the public should visit the Vaccine Record Request page at HealthVermont.Gov to request vaccine records.

Secure Patient Form

This HIPAA Complaint form is the preferred method for existing Vermont Immunization Registry (IMR) users to send Protected Health Information to the Registry Team
Email

Confirmation Emailexample@example.com
This form is not intended for Internal State (VDH) Employees, please visit our Immunization Registry Team Contact form for internal employees.
Your name
Phone Number
Please enter a valid phone number, direct lines preferredFormat: (000) 000-0000.
Is this in reference to a single patient, or multiple patients?
Patient name as it appears in the Immunization Registry

First NameLast Name
Date of Birth

MonthDayYear
Is this in reference to a duplicate patient?
Duplicate patient name as it appears in the Immunization Registry

First NameLast Name
Duplicate patient Date of Birth

MonthDayYear
Screenshot and/or File Upload

Use this field to upload a screenshot or Excel file, if applicable,
Cancelof
Please describe what you need assistance with. Be as specific as possible: if there is a vaccine you need us to look at, please indicate below with the date of the dose.
Should be Empty: