Healthcare VTL Application

HEALTHCARE VTL APPLICATION

Purpose: This form requests issuance of a Vaccination Travel Letter (VTL) verifying immunization records and related clinical information for travel, entry, or other official requirements. By submitting this application the applicant certifies the information below is true and authorizes release of immunization records as expressly described in the Authorization section.

Patient Information

Date of birth:    Gender: Male  Female  Other  Prefer not to say

Emergency Contact

Insurance Information

Medical History

Vaccination Details to be Included in VTL

Include immunizations currently on file (check applicable):
COVID-19   MMR (Measles, Mumps, Rubella)   Yellow Fever   Hepatitis A   Hepatitis B   Polio   Influenza   Other (specify below)

For any included vaccine(s), provide most recent administration information (enter as applicable):
Vaccine name:   Date administered:   Lot number:   Administered by (clinic/provider):

VTL Purpose and Recipient

Destination country / jurisdiction:   Travel dates (approx.): From to

Fees, Processing & Acknowledgements

Processing fee: I acknowledge that there may be an administrative fee for issuance of a VTL. The clinic or issuing office will notify me of any fee and required payment prior to fulfillment. I agree to provide complete and accurate information and understand incomplete applications may be delayed or denied.

Fee acknowledged: I acknowledge potential fees and agree to pay required charges.

Authorization to Release and HIPAA Acknowledgement

Authorization: I authorize the release of my immunization records and any related clinical documentation necessary to prepare the Vaccination Travel Letter (VTL) to the recipient(s) named above. This authorization includes release of vaccine types, dates, lot numbers, administering provider information, and provider signatures as required by the recipient authority.

Privacy acknowledgement: I understand that my health information is protected under applicable privacy laws. I acknowledge that information released pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by the issuing clinic’s privacy practices. I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

By checking the box below I affirm that I have read and understand the Authorization and Privacy Acknowledgement statements and that the information I provide is true and complete.

I authorize release and consent to preparation of the Vaccination Travel Letter as described above.

Applicant Certification

I certify under penalty of perjury that the information provided on this application is true and complete to the best of my knowledge. I understand that knowingly submitting false information may result in denial of the request and may subject me to civil or criminal penalties under applicable law.

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