Mississippi Form 139-R: Appointment, Form 122, and School Filing

To claim a religious exemption from Mississippi’s school vaccination requirements, you fill out the Religious Exemption Request (Form 139-R) at an in-person appointment at your County Health Department, and the Mississippi State Department of Health then mails you a signed Certificate of Medical/Religious Exemption (Form 122) that your school accepts as proof.¹ The visit itself is brief, but processing the paperwork can take up to eight weeks during the summer rush, so start early.²

What Form 139-R Lets You Decide

Form 139-R is not an all-or-nothing document. On the form you check the specific vaccines you are declining on religious grounds, so you can object to one shot while continuing to accept others, or decline all of them. The exemption only applies to immunizations required for school and licensed childcare entry under Mississippi Code § 41-23-37.²

You can download the form from the MSDH website ahead of time to see what information it asks for, though a nurse will go through it with you at the appointment.³

Step 1: Book the Appointment

Call the MSDH scheduling line at 855-767-0170 to set up a visit at your local County Health Department. Walk-ins are not accepted.² If more than one of your children needs an exemption, ask to schedule them together at the same date and time.

Step 2: Gather What You’ll Bring

A valid government-issued photo ID for the parent or guardian.
Your child. Children must attend the appointment in person, and showing up without them means rescheduling.
The name and address of the school or daycare where your child will enroll. This information goes on the form and determines where MSDH mails the approved certificate.

Step 3: What Happens at the Appointment

You start with the standard clinic check-in: a registration form, a notice of privacy practices, and a consent-to-treat form. If your child doesn’t already have one, the health department creates an electronic health record for them.²

Next you watch a short educational video about vaccinations. An MSDH nurse then goes through your completed Form 139-R with you, shares information about the benefits and risks of the vaccines you’re declining, and answers any questions.¹ Siblings seen at the same visit only have to sit through the video once. If you come back on a different day for another child, you watch it again.

Step 4: MSDH Reviews and Issues Form 122

After the nurse confirms your form is complete, County Health Department staff forward it to the MSDH Office of Immunizations. The State Epidemiologist or Deputy State Epidemiologist reviews the request and, if accepted, signs and dates a Certificate of Medical/Religious Exemption (Form 122).¹ Only a signed Form 122 counts as official proof. The original is kept on file at MSDH, and copies are mailed to you and to the school or daycare you listed.²

Step 5: Get Form 122 to the School

MSDH mails a copy directly to the school, but the parent is ultimately responsible for making sure the school has it on file.² Hand your copy to the school nurse, registrar, or front office at enrollment, and keep your own copy somewhere safe. Every enrolled Mississippi student must have either a Form 121 (immunization compliance) or a Form 122 (exemption) on file.⁴

How Long Processing Takes

During peak back-to-school season, it can take up to eight weeks for MSDH to issue your Form 122.² Incomplete forms get kicked back and add more time. If you wait until mid-July to apply, your certificate may not arrive before classes start in August. Late spring or early summer is a safer window. Ask the school’s administration what their deadline is and what happens if the certificate hasn’t arrived by the first day.

What You Have to Do Each Year After Approval

The religious exemption itself is permanent. You do not go through the appointment process again.² A copy of Form 122 does need to be given to the school every year, though, because schools require current documentation on file regardless of when the exemption was first granted.

One update does require action on your part. The Certificate of Compliance (Form 121) that pairs with your exemption is tied to your child’s current age or grade category. When your child moves into a new category, such as the jump to the seventh-grade Tdap requirement, you need an updated Form 121 to go with your existing Form 122. No new appointment is needed. Call the MSDH Office of Immunizations at 601-576-7751 to request the update.² The same number is the one to call if you lose your certificate and need a replacement.

Where the Exemption Stops

An approved exemption does not override outbreak rules. Under Mississippi law, an unvaccinated child who holds an exemption will be excluded from school if a vaccine-preventable disease poses a threat in the community, and the exclusion lasts until the disease is no longer present or no longer a threat.¹ There is no fixed length; it depends on the disease and how quickly the outbreak is contained.

Common Mistakes That Slow Things Down

Waiting until August to call for an appointment, when the eight-week processing window won’t finish before the school year begins.
Leaving fields blank on Form 139-R. Every field is required, and incomplete forms get sent back for correction.
Arriving without the child. The appointment cannot proceed and will need to be rescheduled.
Assuming the school received its mailed copy of Form 122. Follow up with the office directly and bring your own copy to enrollment.
Skipping the yearly submission to the school. The exemption is permanent, but the paperwork on file is annual, and missing it can trigger an enrollment hold.

1
Mississippi State Department of Health. Medical and Religious Exemptions from Vaccinations
2
Mississippi State Department of Health. Questions and Answers: Religious Exemptions from Vaccinations
3
Mississippi State Department of Health. Religious Exemption Request Form 139-R
4
Mississippi State Department of Health. Mississippi School Immunization Requirements