· I have read or had explained to me the Vaccine Recipient Emergency Use Authorization (EUA) Fact Sheet for COVID-19 vaccine risks and benefits. To read the Vaccine Recipient Emergency Use Authorization Fact Sheet for each vaccine visit the website www.cvdvaccine.com to view current EUA: or you may also visit the Local Health Unit or private provider to receive a printed copy of the EUA Fact Sheet.
· I give consent to this COVID-19 provider/staff for the individual named below to be vaccinated with COVID-19 vaccine.
· I hereby acknowledge that I have reviewed a copy of the Provider’s Privacy Notice.
· I understand that information about this COVID-19 vaccination will be included in (WebIZ) Arkansas Immunization Information System.
To My Insurance Carrier(s):
· I authorize the release of any medical information necessary to process my insurance claim(s).
· I authorize and request payment of medical benefits directly to this COVID-19 Provider.
· I agree that the authorization will cover all medical services rendered until I revoke the authorization.
· I agree that the photocopy of this form may be used instead of the original.
My signature below indicates I have read, understand and agree to Release and Assignment of the COVID-19 Immunization Consent Form and Vaccine Recipient Emergency Use of Authorization Fact Sheet (EUA).