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The Florida Medical Exemption Vaccine form plays a crucial role in ensuring that children receive appropriate immunizations while also providing a pathway for those who cannot be vaccinated for medical reasons. This form is governed by several legal statutes and administrative rules, ensuring compliance with state health regulations. It includes sections for parents or guardians to fill out essential information about the child, such as their name, date of birth, and optional social security number. The form also requires documentation of all vaccines administered, with specific spaces for dates and doses of various immunizations, including DTaP, MMR, and Hepatitis B, among others. Importantly, the form distinguishes between three categories of exemption: complete immunization, temporary medical exemption, and permanent medical exemption. Each category requires different information and signatures from a licensed physician or clinic, affirming the child's medical status regarding vaccinations. Detailed guidelines for completing the form are available online, ensuring that families have access to the necessary resources for compliance. By understanding the components and requirements of the Florida Medical Exemption Vaccine form, parents can better navigate the immunization process for their children.

Documents used along the form

The Florida Medical Exemption Vaccine form is an important document for parents or guardians seeking to exempt their child from vaccination requirements due to medical reasons. Alongside this form, several other documents are commonly used to ensure compliance with state regulations regarding immunizations. Below is a list of these related forms.

  • Certificate of Immunization (DH 680): This form provides a comprehensive record of a child’s immunizations. It includes details about each vaccine received, dates administered, and the child's personal information. Schools and childcare facilities often require this certificate for enrollment.
  • Temporary Medical Exemption Form: This document is used when a child cannot receive certain vaccinations for a limited time due to medical reasons. It must specify the duration of the exemption and is typically valid for a set period.
  • Permanent Medical Exemption Form: This form is for children who have a long-term medical contraindication to vaccinations. It requires a physician’s certification stating that the child cannot receive specific vaccines due to health issues.
  • Immunization Guidelines (DH Form 150-615): This guideline provides detailed instructions on immunization requirements for schools, childcare facilities, and family daycare homes in Florida. It assists parents and guardians in understanding the vaccination process and necessary documentation.

Having these documents readily available can streamline the process of obtaining medical exemptions and ensure compliance with Florida's immunization laws. It is essential for parents to understand each form's purpose and requirements to protect their child's health and educational opportunities.

Similar forms

The Florida Medical Exemption Vaccine form shares similarities with the Certificate of Immunization for K-12 students. Both documents serve to verify a child's vaccination status for school attendance. The Certificate of Immunization includes details about the specific vaccines received, while the Medical Exemption form specifically addresses situations where a child cannot receive certain vaccines due to medical reasons. Both forms require signatures from authorized medical personnel, ensuring that the information provided is accurate and validated.

Another related document is the Temporary Medical Exemption form. This form is issued when a child is temporarily unable to receive vaccinations, often due to a recent illness or ongoing medical treatment. Like the Florida Medical Exemption Vaccine form, it requires a healthcare provider's signature and includes an expiration date. This ensures that the exemption is valid for a limited time, prompting parents to keep track of their child's immunization schedule and update their records as needed.

The Immunization Record is another document that bears resemblance to the Florida Medical Exemption Vaccine form. This record details all vaccinations a child has received, including dates and types of vaccines. While the Medical Exemption form focuses on specific exemptions, the Immunization Record provides a broader overview of a child's vaccination history. Both documents are essential for schools and childcare facilities to assess a child's eligibility for attendance based on immunization status.

The Health History form used in schools is also similar. This document collects information about a child's overall health, including any medical conditions that may affect vaccination. Like the Medical Exemption form, it allows parents to communicate important health information to school officials. However, the Health History form is more comprehensive, covering various health aspects beyond immunizations, while the Medical Exemption form is specifically tailored to vaccination contraindications.

The Physician's Statement for Immunization Exemption is another document that aligns with the Florida Medical Exemption Vaccine form. This statement is often required when parents seek exemptions for their children based on medical reasons. It must be completed by a licensed healthcare provider and includes specific details about the medical condition preventing vaccination. Both documents emphasize the importance of professional medical evaluation and endorsement in the exemption process.

The School Health Assessment form is also relevant. This form is used to evaluate a child's overall health and readiness for school, including their immunization status. While it may not focus solely on vaccination exemptions, it still plays a crucial role in ensuring that children are healthy and up-to-date with their immunizations. The Medical Exemption form complements this by providing a clear path for children who cannot receive certain vaccines due to medical issues.

Lastly, the Exemption Request form for religious or philosophical beliefs is similar in that it allows parents to opt-out of vaccinations. While the Florida Medical Exemption Vaccine form is strictly for medical reasons, the Exemption Request form addresses personal beliefs. Both forms require parental input and often need to be submitted to schools or childcare facilities to ensure compliance with state vaccination laws. They highlight the balance between public health requirements and individual rights.

Obtain Answers on Florida Medical Exemption Vaccine

  1. What is the Florida Medical Exemption Vaccine form?

    The Florida Medical Exemption Vaccine form is a document that allows parents or guardians to request an exemption from certain vaccination requirements for their children. This form is specifically designed for situations where a child has a medical condition that contraindicates vaccinations. It helps ensure that children who cannot receive vaccines for valid medical reasons are still able to attend school or daycare.

  2. Who can fill out the Medical Exemption form?

    A licensed physician or authorized healthcare provider must complete the Medical Exemption form. They will assess the child's health and determine if a medical exemption is appropriate. The provider needs to provide a valid clinical reason for the exemption, ensuring that the child's health is prioritized.

  3. How do I submit the Medical Exemption form?

    After filling out the form, you should submit it to your child's school or daycare facility. It is essential to keep a copy for your records. Make sure to check with the specific institution for any additional requirements they might have regarding the submission process. Schools may have deadlines for submitting the form, so it’s a good idea to act promptly.

  4. What happens if my child has a temporary medical exemption?

    If your child has a temporary medical exemption, the form will indicate an expiration date. This means that while your child is exempt from vaccinations for a limited time, they will need to complete the required immunizations before the expiration date. It’s crucial to follow up with your healthcare provider to ensure that your child receives the necessary vaccinations once they are medically indicated.

Document Preview

FLORIDA CERTIFICATION OF IMMUNIZATION

Legal Authority: Sections 1003.22, 402.305, 402.313, Florida Statutes; Rule 64D-3.046, Florida Administrative Code

 

 

 

 

 

 

 

 

 

 

LAST NAME

 

FIRST NAME

 

MI

 

DOB (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

PARENT OR GUARDIAN

 

CHILD’S SS# (optional)

 

STATE IMMUNIZATION ID# (optional)

 

 

 

 

 

 

 

 

 

 

Directions:

Enter all appropriate doses and dates below.

Sign and date appropriate certificate (A, B, or C) on form.

 

 

 

 

 

 

See DH Form 150-615, Immunization Guidelines - Florida Schools, Childcare Facilities and Family Daycare Homes

(0DUFK

for information and instructions on form completion. Guidelines are available at:

 

 

www.immunizeflorida.org/schoolguide.pdf.

 

 

 

 

 

 

 

 

VACCINE

 

DOE

Dose 1

 

Dose 2

 

Dose 3

 

Dose 4

 

Dose 5

 

 

CODE

MM/DD/YY

 

MM/DD/YY

 

MM/DD/YY

 

MM/DD/YY

 

MM/DD/YY

DTaP/DTP

 

A

 

 

 

 

 

 

 

 

 

DT

 

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tdap

 

P

 

 

 

 

 

 

 

 

 

Td

 

Q

 

 

 

 

 

 

 

 

 

Polio

 

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hib

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR (Combined)

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Separate)

G, H

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measles (dose 1)

 

Measles (dose 2)

 

Mumps (dose 1)

 

Mumps (dose 2)

 

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rubella (dose 1)

 

Rubella (dose 2)

 

 

 

 

 

 

Hepatitis B

 

J

 

 

 

 

 

 

 

 

 

Varicella

 

K

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella Disease

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year

PneumoConju N

Select appropriatebox(es)

Certificate of Immunization forK-12

Part A-Complete

DOE Code 1: Immunizations are complete K-12 (Excluding 7th grade/middle school requirements)

DOE Code 8: Immunizationsare complete for 7th grade

I have reviewed the records available,and to the best of my knowledge, the above named child has adequately been immunized for school attendance, as documented above.

Temporary Medical Exemption

Expiration date:

Part B-Temporary

 

Part B (For children in daycare, family daycare homes, preschool, kindergarten and grades 1 through 12 who are incomplete for immunizations in Part A) Invalid without expiration date. DOE Code 2

I certify that the above named child has received the immunizations documented above and has commenced a schedule to complete the required immunization. Additional immunizations are not medically indicated at this time.

Permanent Medical Exemption

Part C-Permanent

Part C (For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption.) DOE Code 3 ________________________________________________________________________________________

I certify the physical condition of this child is such that immunizations as indicated in Part C above are medically contraindicated.

Physician or Clinic Name:

Physician or

_________________________________________________

Authorized Signature: ____________________________________

_________________________________________________

Issued By:_____________________________________________

_________________________________________________

Date: _________________________________________________

DH 680 (Jul 2010)

Dos and Don'ts

When filling out the Florida Medical Exemption Vaccine form, it is important to adhere to specific guidelines to ensure a smooth process. Here are four things you should and shouldn't do:

  • Do ensure that all information is accurate and complete. Double-check names, dates, and any medical details provided.
  • Do sign and date the appropriate certificate on the form. Your signature confirms the information is correct.
  • Don’t leave any sections blank. Incomplete forms can lead to delays in processing or denial of the exemption.
  • Don’t provide false information. Misrepresentation can have serious consequences for both the child and the responsible adult.