COVID-19 Vaccine Intake Consent Form

Patient Name *

First

Last

Patient Date of Birth *

Patient Gender *

Male
Female

Mobile Phone

Home Phone Number

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Allergies:

Race/Ethnicity *

American Indian or Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Black or African American
Hispanic
Not Hispanic or Latino
Other Race
Unknown
White

Prescription Insurance:

Are you the primary cardholder? *

Please include the primary cardholder’s DOB, relationship and 0# found next to the Member ID on the insurance card

Prescription Benefit Plan Name *

DOB

Cardholder ID #

RX Group ID

BIN

PCN

Medicare Fields *

Is the patient age 65 or older or Medicare eligible?

Medicare Part A/B ID Number (MBI) Note: MBI is required for all patients Age 65 or older, or Medicare eligible. Refer to your Medicare Red, White, And Blue card

Medical Insurance:

Medical Insurance Provider *

Cardholder ID #

Group ID

Payer ID

Health benefit plan. *

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan.

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration’s COVID-19 Program for Uninsured Patients, please provide either (a) a valid Social Security number, (b) state identification number and state of issuance, OR (c) a driver’s license number and the state of issuance.

Social Security Number *

Driver’s License Number & State *

Has this patient been vaccinated with the Covid-19 vaccine? *

Vaccine Administration Information for Immunizer/Pharmacist use only

Vaccine Brand (Pfizer, Moderna, Astra Zeneca. Johnson and Johnson)

Date dose #1 given

Date dose #2 (if necc) given

Lot#

Exp. Date

Site *

Clinic *

CONSENT FOR SERVICES: I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.

AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize Adler’s Pharmacy LTC to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

DISCLOSURE OF RECORDS: I understand that Adler’s Pharmacy LTC may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also understand that Adler’s Pharmacy LTC will use and disclose my health information as set forth in the Adler’s Pharmacy LTC Notice of Privacy Practices (copy is available by requesting a paper copy from the pharmacy).

COVID-19 Vaccine Intake Consent Form

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