Iowa HHS's medical exemption certifies that required vaccines would be injurious to the health of a child or a household member, or that giving MMR or varicella now would violate the 28-day spacing after a previous live vaccine. The clinician checks only the vaccines that are medically contraindicated and can set an expiration date for review.
An Iowa-licensed physician (MD or DO), nurse practitioner or physician associate selects the reason and vaccines, records an expiration date if needed, and signs with their Iowa license number.
Download the current version from the source each time; forms change without notice.
Medical Certificate of Immunization Exemption
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Only an Iowa-licensed physician (MD or DO), nurse practitioner or physician associate. The form says it is valid only with such a signature, and the signer enters their Iowa license number. Nurses and certified medical assistants, who can sign the regular Certificate of Immunization, cannot sign the exemption.
Only if the clinician sets a date. When the exemption should end or be reviewed later, an expiration date is recorded on the certificate. Exemptions based on live vaccine spacing must carry an expiration date of no more than 60 days.