Please complete this form to update contact information associated with yourself or your dependent(s) in the State of Alaska Immunization Information System (VacTrAK).

If you believe that you have duplicate records, this form can also notify Docket support to review your VacTrAK record. 

Updates to phone numbers and email addresses can be made through verification of a valid form of state or federal identification. For any other changes (e.g., first and last name, legal sex, physical/mailing address, or listed vaccinations), please contact your health care provider.

This form is HIPAA compliant, and your information will be kept confidential.

Request to update contact information for:

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* 1. Legal First Name

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* 2. Legal Middle Name (optional) 

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* 3. Legal Last Name

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* 4. Previous Legal Last Name(s) (optional)

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* 5. Date of Birth

Date

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* 6. Legal Sex (The sex listed on ID)

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* 7. Race
Race is a required field in VacTrAK, and changes to contact information cannot be saved without this data.

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* 8. Ethnicity
Ethnicity is a required field in VacTrAK, and changes to contact information cannot be saved without this data.

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* 9. Phone Number (XXX-XXX-XXXX)
This is the number that can be used to verify identity for Docket and will be listed in VacTrAK as the primary number. 

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* 10. Is there an additional phone number you would like added to VacTrAK?

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