RELEASE OF CONFIDENTIAL INFORMATION

Connecticut Immunization Information System (CT WiZ)
CT Department of Public Health Immunization Program
410 Capitol Ave. MS #11 MUN Hartford, CT 06134-0308
Phone (860) 509-7929 Fax (860) 707-1925
Website: https://portal.ct.gov/dph/individuals-and-families/immunizations

I, Requestor's Full Name , hereby authorize my or my child’s immunization history to be released to the Connecticut Immunization Information System (CT WiZ).

Patient's Full Name

First NameMiddle NameLast Name

Patient’s Date of Birth

MonthDayYear

Relationship to the above:

Other, Specify

This immunization record will be released/sent to:

Name

Fax Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / ZIP Code

PLEASE NOTE:

The requestor must provide proof of identification (ID), as listed below, in accordance with Connecticut General Statutes Section 19a-7h-4 release of information by the Connecticut Immunization Information System (CT WiZ):

official photo ID; e.g. driver’s license, passport or state issued ID card

OR any two (2) of the following:

written ID of employer
current auto registration
current auto registration
utility bill with name and address
current checking deposit slip with name/address
current voter registration card

Please submit the requestor’s proof of ID (choose one method below):

CT WiZ submissions: https://ctwizsubmissions.dph.ct.gov , or
Fax: (860) 707-1925, or
Mail: CT Department of Public Health Immunization Program,

410 Capitol Ave., MS #11 MUN
Hartford, CT 06134

This authorization will expire within 10 business days of my signature. I understand I may revoke this authorization at any time by notifying the Connecticut Department of Public Health Immunization Program in writing. I understand the revocation will not apply to information that has already been released in response to this authorization.

Patient or Parent/Guardian Signature

Date

MonthDayYear

Upon submission of the requestor’s proof of ID and submission of this Release of Information, the Connecticut Immunization Program will review and respond to your request for the immunization record.

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