MyVaxIndiana

Please click here to download the authorization form to register your cell phone number and email address in CHIRP.

Note: If you have already downloaded and filled all the details, please enter the details below and upload the authorization form, and click on "Upload" button to send these details to MyVaxIndiana support.

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Cell Phone*

Email Address*

Document Type*

Valid ID

Authorization Form

Valid ID/Authorization Form*

Note: Your authorization form/ID will be securely emailed to the CHIRP helpdesk to verify the information you provided and to update your patient record and will never be shared. You will receive an email once verification and update is complete (5-10 business days).

By checking this box, I acknowledge that I have read and understand this authorization. I understand that immunization records to be disclosed will be disclosed in accordance with this authorization.* This acknowledgement is required

By checking this box, I declare under the penalty of perjury under the laws of the State of Indiana that the foregoing is true and correct, and that I am authorized to sign this release on the patient’s behalf.* This declaration is required