COVID-19 Vaccination Screening & Consent Form

Medicare Insurance Information
Is the patient age 65 or older and/or Medicare Eligible?

Yes No
Medicare Part A/B ID Number (MBI)
Note: MBI is required for all patients age 65 and older, or Medicare eligible. Refer to your Medicare Red, White, and Blue card. If you do not have a Medicare card, please enter your Social Security Number in this field.
Prescription Insurance Information
Are you the Primary Cardholder for your prescription insurance

Yes No
Cardholder Name
Cardholder Date of Birth
Prescription Benefit Plan Name
Cardholder ID #
Rx Group ID
BIN #
PCN
Medical Insurance Information
Medical Insurance Carrier Name
Cardholder ID #
Group ID
Payor ID
Are you the Primary Cardholder?

Yes No
Cardholder's Date of Birth
If you are uninsured, you must check the box below to attest that the following information is true and accurate:

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 or State Identification Number
State of Issuance for SSN or State ID
Driver's License Number
State of Issuance for Driver's License

Consent
I have read or have had explained to me the information provided in the Emergency Use Authorzation (EUA) Factsheet or Vaccine Information Statement about COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of COVID-19 vaccine and ask that the vaccine be administered to me or to the person named above for whom I am authorized to make this request.
Signature

Clear
Date

Month Day Year
Date
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COVID Vaccination Screening & Consent Form