Provider Forms and Information

COVID-19 Vaccine Distribution and Reporting (1/11/2021)

To be able to order COVID-19 vaccine online, receive distributions of vaccine, and fulfill mandated reporting of COVID-19 immunizations to the CDC, your organization, clinic sites, and staff members must be enrolled in the RIDE/Healthy Futures Immunization Registry:

  • Step 1: Register your organization and clinic sites - Complete and return a Registry Provider Agreement Form. You will be issued an "IIS ID", which is required for enrollment in COVIDReadi/CalVax to be eligible for COVID-19 vaccine distribution.
  • Step 2: Register your staff members - Complete and return a Registry Request For Access Form for each member of your staff who will be entering immunizations and/or managing vaccine inventory. Note that at least one person on your team must be designated as a Clinic Administrator, to allow them to manage vaccine inventory and request COVID-19 vaccine.
  • Step 3 (optional): Set up Electronic Data Exchange - If your organization would like to send data electronically from your EHR system, please click here for more information. This is not required for COVID-19 vaccine distribution.

Once your organization, clinic sites, and staff members are enrolled, your COVID-19 immunizations will be automatically reported to CDC.

If you have any questions, please contact the Registry Help Desk at:

To further assist our provider community, this section of the website provides forms, documentation, and links to information about important immunization topics.


Provider Forms

Patient Disclosure

NOTE: The Patient Disclosure forms below REPLACE all previous copies. Currently enrolled providers should discard their old forms and begin using the forms below.

Patient Refusal