Colorado Immunization Information System
Opt Out-Form
The Colorado Immunization Information System (CIIS) is a confidential, computerized, population-based system that collects and
consolidates immunization data for Coloradans of all ages from a variety of sources and provides tools for designing and sustaining
effective immunization strategies to prevent disease and reduce healthcare costs. If your healthcare provider participates in CIIS,
they are able to view vaccines that you/your child received in the past as well as any vaccines recommended for you/your child at
the time of the visit. Immunization forms needed for child care, school and camp enrollment can be printed from the CIIS web
application by your healthcare provider. You can also print these forms yourself directly from the secure CIIS Public Portal. See
here for guidance.
Information in CIIS can only be released to and accessed by:
● The individual or the individual’s parent/legal guardian.
● The physician, clinic, hospital or licensed healthcare practitioner treating the individual.
● A school, child care/preschool or college/university where the individual is enrolled.
● A managed care organization or health insurer where the individual is enrolled, if the organization or health insurer pays for
immunizations.
● People or entities that have contracted with the State of Colorado for the implementation and operation of CIIS.
● The Department of Health Care Policy and Financing, for individuals enrolled in Health First Colorado (Colorado’s Medicaid
program).
● The Colorado Department of Public Health and Environment and local public health agencies to the extent necessary for
the treatment, control, investigation and prevention of vaccine-preventable diseases.
Anyone who releases information in CIIS to an unauthorized party commits a crime and can be punished. Under Colorado law, you
have the right to exclude your/your child’s immunization information from CIIS at any time. If you choose to opt out of CIIS, the
immunization information is removed and you are responsible for keeping your/your child’s immunization records. If you
decide to opt you/your child back into CIIS, you can have your healthcare provider resubmit the immunization records to CIIS.
NOTE: CIIS works on a search function; system users have to search for and find an individual in CIIS prior to viewing or updating
the individual’s record. The following demographic information is kept in CIIS for opt-out individuals: First Name, Last Name,
Date of Birth, Gender, City, County, and Zip Code. This information is retained to prevent CIIS users from adding opt-out
individuals back into CIIS. As immunization data may be provided to CIIS from multiple sources, such as healthcare providers,
school officials, or parents/guardians, retaining limited demographic information is the only way to guarantee that if new
immunization information is received by CIIS after the individual has opted out, the information will not be included in CIIS.
Patient Information: Please print clearly.
Last Name:
First Name:
Middle Name:
Date of Birth:
Gender: □ Female □ Male
Street #:
Street Name:
Street Type (e.g. Ave.):
Unit #:
P.O. Box:
City:
State:
Zip Code:
By signing this Opt-Out form, I confirm that I am the individual or parent/legal guardian of the individual listed above. I choose to
have immunization information for myself/my child excluded from CIIS. I understand that all immunization information will be
removed from the CIIS record. I can continue to receive vaccines for myself/my child from my healthcare provider even if the
immunization information is excluded from CIIS.
___________________________________________________________________________________________________
(Please print) Individual or Parent/Legal Guardian Full Name
__________________________________________________________________________ ___________________
Signature of Individual or Parent/Legal Guardian Date
Email Address for confirmation (confirmation will not be sent if no email is provided): ___________________________________
It is your responsibility to email, mail or fax this form to:
Colorado Department of Public Health and Environment
Attn: Colorado Immunization Information System Program DCEED-IMM-A3
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Fax: 303-758-3640
Email: [email protected]
Updated January 2022
