CAIPA COVID-19 VACCINATION FORM

CAIPA COVID-19 VACCINATION FORM

This is a PREREGISTRATION application, as we DO NOT have an estimate time arrival for the vaccine in our facility. We will call you once our Moderna vaccine is available. If you are 65 years or older, please also apply to other vaccination sites to have the earliest available date.
Patient Name *
DOB *
Gender *
Marital Status
S – Single D – Divorced M – Married
W – Widowed V– CivilUnion U-Unknown
SEPARATED – Legally Separated
PARTNER – Life Partner
Email Address *

Street Address Line 2
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian/ Surrogate (if applicable, please print)
Phone Number *
Please enter a valid phone number.
Ethnicity *
Ethnicity Key:

DECL – Declined HIS – Hispanic Origin

NHL – Non-Hispanic Origin

UNK - Unknown
Race *
Race Key:

AIA – Native American orAlaskan ASN – Asian

BAA – African Americanor Black DECL – Declined

NHP – Native Hawaiian or Pacific Islander

WHT – White OTH – Other or Multiracial
Primary Care Physician Name
Primary Care Physician Address
Primary Care Physician Phone Number

Area Code Phone Number
Insurance Information
Insurance Carrier
Insurance#
Insured Name
Relationship to Insurer:

Self Child Spouse Other
Medicare#
Medicaid#
Insured DOB
Secondary Insurance Information
Secondary Insurance Carrier
Insurance#
Insured Name:
Medicare#
Medicaid#
Insured DOB
Relationship to Insurer:

Self Spouse Child Other
Social History
Tobacco:

No Yes Quitted
Alcohol:

No Yes
Have you been to Flushing Endoscopy Center?

Yes No (New Patient)
Agreement

I here by authorize direct payment of medical benefits to CAIPA Physicians for services rendered by the office. I understand that I am financially responsible for any balance if my insurance is terminated or the service is not covered.
Printed Name of Patient / Guardian *
Signature *

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CONSENT FORM

Privacy Act Statement-The information contained on this form contains confidential patient information that is legally protected by the privacy Act of 1974, 5 U.S.C. 522, and the Health Insurance Portability and Accountability Act of 1996, P.L. 104-109 and other applicable federal and state laws. A photocopy of this assignment is considered as valid as the original. Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and healthcare operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect anydisclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health InsurancePortability and Accountability Act of 1996 (HIPAA).
The patient understands that:
- Protected health information may be disclosed or used for treatment, payment, or health care operations;
- The Practice has a Notice of Privacy and that the patient has the opportunity to review this Notice;
- The Practice reserves the right to change the Notice of Privacy Practices;
- The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions;
- The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
Print Name *
Signature *

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