Electronic Confirmation

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Florida Department of Health:
Authorization to Disclose Confidential Information

  Disclaimers:
  1. Filling out this form does not guarantee that the requested patient record will be found in Florida SHOTS. Initial search may be conducted based on information provided in the request form. If multiple matches were found or no matches were found during the initial search, Florida SHOTS staff may need to contact you to obtain additional information before the correct record can be identified and released.

  2. If you are looking for your COVID-19 vaccination record, please allow at least 2 to 3 weeks after the administration date for your record to be in Florida SHOTS.

  3. This form is for use only by individuals aged 18 years and over to request their own COVID vaccination record. DO NOT use this form to request immunization records for another individual. Please have them submit their own request.

  4. Currently records of minors (aged 17 years and below) are not available through this request. Please contact your immunization provider or your local county health department to request the records.
All required fields are marked by * and must be completed:
Patient Information
 
 
Requestor Information
 
 
Information to be Disclosed *
 
 
Method of Disclosure *  (Select one item from the list below)
 
 
Purpose of Disclosure *  (Select one item from the list below)
 
 
Requestor Identity Proof
 
 
Electronic Signature