Forms

Instructions

• Choose a form below. Select "view" to see the form (in PDF format). To return to this page, simply close the new window.
• For instructions on opening, saving, and printing PDF files, click here.

---

Forms for Providers:
Online Access Forms
User Confidentiality for Online Access and Acceptable Use Protocol
Batch Submittal
Data Exchange Interface (DEI) Forms
Paper Reporting
Private Provider Registration
Provider Contact Update
Forms for Individuals, Parents, and Guardians:
Child Enrollment
CIR Reporting Consent Form for Individuals 19 Years or over
Correcting Immunization Records
Parent Request for Immunization Record

---

Online Access to the CIR view (168 KB, 2 pages)
To access the Online Registry (OR) through the website, each health care facility or practice designates a Security Administrator (User Manager). The OR Acceptable Use Protocol and Security Administrator (User Manager) Confidentiality Statement must be read and signed by the designated Security Administrator and returned by mail or fax to the CIR along with the Security Administrator (User Manager) User ID/Password Request Form (Private) (PDF file, 232 KB, 1 page) or Security Administrator (User Manager) User ID/Password Request Form (Facilities) (PDF file, 160 KB, 1 page) to obtain online access/reporting privileges.

---

User Confidentiality for Online Access and Acceptable Use Protocol view (160 KB, 2 pages)
To access the Online Registry (OR) through this website, each health care facility or practice designates a Security Administrator. The Security Administrator must read, sign, then mail or fax the Acceptable Use Protocol and Security Confidentiality Statement along with the Security Administrator (User Manager) User ID/Password Request Form (Private) (PDF file, 232 KB, 1 page) or Security Administrator (User Manager) User ID/Password Request Form (Facilities) (PDF file, 160 KB, 1 page) for Online Access to the OR. He or she must have each additional user read and sign a User Confidentiality Statement for Online Access and keep those on file at the site.

---

Batch Submittal view (PDF file: 88 KB, 1 page)
This form is a cover sheet that accompanies and identifies each batch of paper reporting forms you mail to the CIR.

---

Data Exchange Interface (DEI) Forms view (210 KB, 13 pages)
Instructions, specifications, forms and other related DEI documents needed for the Data Exchange Interface. DEI Instructions, Specifications and Forms

---

Paper Reporting
Immunizations are to be reported within 14 days of administration according to the NYC health code. Providers fill out demographic and immunization information and mail original (white copy) reporting forms with a completed Batch Submittal Form. Please use the contact information below to send completed immunization registry reporting forms and to order forms for your office.

New York Citywide Immunization Registry
P.O Box 90490
Binghamton, NY 13902
Email: cirforms@srcp.com
Phone: (800) 238-0130
Fax: (212) 208-4641
-or-
Order Online

---

Private Provider Registration view (91.9 KB, 1 page)
Private office-based providers need to register to report and to have access to the Registry. Must be mailed or faxed. Providers also may register online.

---

Provider Contact Update view (67 KB, 2 pages)
To update the contact information for your facility or practice. (You can also update this information online by clicking here.)

---

Child Enrollment Form (for Parents/Guardians to complete) view (17 KB, 1 page)
To enroll your child in the Citywide Immunization Registry.
CIR Reporting Consent Form for Individuals 19 Years or over view (61 KB, 1 pages)
To report immunizations administered to individuals 19 years old and over to the Registry, a written consent will be needed. This is a sample form that the providers may use to obtain consent. A copy of the consent should be kept in the individuals’ medical record.

---

Correcting Immunization Records
Instructions for Parents:
The Parent/Guardian Child Enrollment Form can be used to change or update information in a child's record. Must be mailed or faxed. Send the following information to the CIR:

• A completed Child Enrollment/Update Form (PDF: 138 KB, 1 page)
  
• A clear copy of your child’s Lifetime Health Record or other immunization card.
  
• Mail or Fax the completed Child Enrollment/Update Form and Lifetime Health Record.

---

Parent Request for Immunization Record view
Form for parents to request an official copy of a child's record. Must be mailed or faxed. (PDF file: 17 KB, 2 pages, includes instructions).

---

Mail:
New York City Department of Health and Mental Hygiene
Citywide Immunization Registry
125 Worth Street, CN #64R
NY, NY 10013-4089
Phone: (212) 676-2323
FAX: (212) 676-2314