Healthcare Provider MCIR Agreements and Forms

Click directly on text within square to view or open applicable form.

Please complete an agreement located below, and submit it to the MCIR Help Desk
for approval to secure Michigan Care Improvement Registry (MCIR) access. 

Agreement issued to all immunizing Public and Private Providers and Pharmacies requesting MCIR access and user rights.

Agreement issued to Health Care Organizations requesting view only MCIR access and user rights.

Agreement issued to Universal Hospital HepB, All-Hazard, non-Administering pharmacies requesting MCIR access.

A form for a Facility, Organization and its user(s) to access the MCIR via Query Only. 

This form is to be filled out by a physician regarding a child with a valid medical contraindication to a particular vaccine.

This form is for changes including spelling or DOB corrections, legal name changes, adoptions, or to merge duplicate records.

B&W Version for printed, scanned, or faxed copies.

P4M Adoption Tip Sheet

This form is for modifying or deleting immunizations entered into a MCIR record by another provider.

B&W Version for printed, scanned, or faxed copies.

Childcare, School MCIR Agreements and Forms

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Form for individuals who are assigned to be the new School/Childcare Site
Administrator of an established School/Childcare site, replacing the existing Site Administrator.

Agreement issued to a new facility or to re-enable a current site that is not active.

Instructions and form regarding a School Building and/or Childcare Building name change.

Schools/Childcares can use this form to eradicate spelling errors, modify DOB, or merge duplicate records. Parents/Guardians must complete the Request to Change Information form for legal name changes.

Post-Secondary Institution & Organizational MCIR Agreements and Forms

Click directly on text within square to view or open applicable form.

Please complete an agreement located below, and submit it to State of Michigan Helpdesk for approval to secure
Michigan Care Improvement Registry (MCIR) access.

Agreement for employers to
view employee vaccine
status only with previous
employee consent.