I will review Vaccine Information Sheet corresponding to the selected vaccine in the email received after submitting this form, and/or have had explained to me the information on the sheet about the vaccine. prior to injection. I have had the chance to ask questions and they were answered to my satisfaction. I believe I understand the benefits/risk of the vaccine and ask that it is given to me or the person named above for whom I am authorized to make this request.
I am aware of the pharmacy’s policy that billing my insurance/Medicare on my behalf is a courtesy provided by them and that I am responsible for any deductible or co-insurance amounts. I understand that Medicare may pay part of the amount billed by the pharmacy or part of Medicare'’ allowable amount whichever is less and that I am responsible for the remaining amount. Also, I understand that if any of my claims are rejected by my insurance/Medicare, I will pay the pharmacy for the full amount of the claim. I recognize my obligation to forward payment to the pharmacy for any payment received by me due to them.
INSURANCE LIFE-TIME AUTHORIZATION:
I request payment under the medical insurance program be made to me or the provider names above on any bills for service. I authorize the above named provider to release to the Social Security Administration or its intermediaries or carriers any information needed for this claim or any related Medicare claim. I further permit a copy of this authorization to be used in the place of the original.
If for some reason, the patient is mentally or physically unable to sign this card, the signature of a relative, friend, legal guardian, representative payee, or the representative of any institution providing care is acceptable. The name of the patient should be shown on the signature line followed by “BY”, and the signature and address of the individual signing for the patient. The mental or physical problem, which does not allow the patient to sign, and the relationship of the person signing on their behalf, must also be indicated on this card. A physician or supplier’s office cannot sign on behalf of a patient except under extraordinary circumstances. Please contact the Medicare Office if you need further details.
I also received the Notice of Privacy Practices.
DATE OF VACCINATION:________________ Signature of Administrator:_____________________
SITE OF INJECTION: R OR L Deltoid