Try for free

Mississippi Form 139-M: Medical Exemption Request

Mississippi grants medical exemptions from school and child care vaccines only after state review. The child's physician uses this request to set an exemption status for each required vaccine and explain the medical reason; the State Epidemiologist or Deputy State Epidemiologist reviews it and, once accepted, issues the Certificate of Medical Exemption (Form 122), the only document that proves the exemption.

Who completes it

The child's Mississippi-licensed pediatrician, family physician or internist completes and signs the whole form, including Mississippi medical license number and NPI. A child's out-of-state tertiary care physician may also complete it, with case-by-case review.

Submitting and payment

How to submit it
The physician sends it to the State Epidemiologist or Deputy State Epidemiologist at MSDH's central office in Jackson by mail or fax. MSDH mails a copy of Form 122 to the parent and the physician.

Good to know

  • An exemption status is required for every vaccine listed: permanent, temporary with an expiration date, or no exemption. Hib applies to child care only and Tdap to 7th grade entry.
  • By signing, the physician declares they discussed vaccine benefits and risks with the parent and warned that the child may be excluded if vaccine-preventable disease threatens the community.
  • Incomplete requests are not accepted, and MSDH contacts the requesting physician. The original Form 139 and Form 122 stay on file at MSDH and are reviewed periodically for validity.
  • Religious exemptions use a separate parent form, 139-R, completed at a county health department appointment that includes a vaccine education video and a discussion with an MSDH nurse.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Exemption Request

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Is Form 139-M proof of a medical exemption in Mississippi?

No. The request itself is not an exemption. Only the Certificate of Medical Exemption (Form 122), signed and dated by the State Epidemiologist or Deputy State Epidemiologist, is official proof. MSDH mails copies of that certificate to the parent and the requesting physician after the request is accepted.

How long does a Mississippi medical exemption last?

MSDH says an exemption lasts no less than one school year unless the request indicates otherwise. The physician shapes the duration on the request by marking each vaccine as permanent or temporary and giving an expiration date for any temporary exemption.

Who can sign a medical exemption request in Mississippi?

Only the child's pediatrician, family physician or internist licensed in Mississippi, or an out-of-state tertiary care physician for a child receiving specialized care outside the state. Out-of-state requests are reviewed case by case and may prompt follow-up questions from the State Epidemiologist.