DHHS → Request for Demographic Changes in ImmPact

Request for Demographic Changes in ImmPact

The Maine Immunization Program can change or update your contact information within the ImmPact record. This information will include phone number and email address. All other demographic information changes must be completed by your healthcare provider.

Field marked with * are required.

Please enter in the patient’s information below

Legal first name

Legal Middle Name

Legal Last Name

Maiden Name or Former Last Name

Date of Birth (MM/DD/YYYY)

Phone Number

Street Address

City

Zip Code

Mother's Maiden Name

Requester’s relationship to patient (please check one)

Self

Patient or Legal Guardian

What change is being requested for the patient’s ImmPact record? (please provide updated information below)

Updated phone number

Updated email address

By entering your full name below, you certify under penalty of perjury that you are the Patient or Parent/Guardian of the minor patient and are therefore authorized to make decisions for the patient listed on this form.

Name

Date