Authorization To Release Healthcare Information
Disclaimer: Finding a match in this initial search does not guarantee that the requested patient record will be found in CAIR. Likewise, this initial search may identify multiple matching records and CAIR staff may need to contact you to obtain additional information before the correct record can be identified and released. If additional identifying information is requested but not returned within 7 business days, the record request will be denied, Please allow at least 14 business days for resolution of each record request.
Required fields are marked by an *
Patient Information
First Name *
Middle Name
Last Name *
DOB *
Gender *
Relationship To Patient *
Name of Parent/Guardian (if patient is a minor *) 
First Name:
Last Name:
Phone * (  -
Requestor Information

Name *
Address *
City *
Zip Code *
Please indicate below how and where you would like your/your child’s immunization record sent (choose 1 method only)
Email  
Requestor: Please upload a copy of a current ID with picture (i.e. current driver’s license). If the child is a ward of the court, or you have been given custody of the child, please include a copy of the documentation authorizing you to receive a copy of the records. If you are from a foster care agency please include a copy of your badge with this request.
  File Name :
   Electronic Signature
  By checking this box and by entering your full name below, you are declaring under penalty of perjury under the laws of the State of California that you are the Patient or Parent/Guardian of the patient and are therefore authorized to access the patient’s CAIR immunization /Tb record.
 
Full Name *   Date  
 
* THIS AUTHORIZATION EXPIRES NINETY (90) DAYS AFTER IT IS SIGNED
For any questions regarding these Disclosure and Share Policies, contact the CAIR Help Desk 800-578-7889 CAIRHelpDesk@cdph.ca.gov
View CDPH’s privacy policy