I hereby give my consent to the Immunogenomics Vaccine Clinic ("IMMUNOGENOMICS") to administer the vaccine (the "service") I have requested below. With my initials, I certify that: I am, (I) the patient and at least 18 years old of age; (ii) the parent or guardian of the minor patient; or (iii) the legal guardian of the patient; or (iv) a person authorized under the law of another state or a state court order to consent for the child; OR The persons identified under (ii), (iii), or (iv), in the preceding sentence are unavailable and I have authority to consent to the immunization of thechild because I am a (I) grandparent; (ii) adult brother or sister; (iii) adult aunt or uncle; (iv) stepparent; or (v) another adult who has actual care, control, and possession of the child and has written authorization to consent for the child from a parent, managing conservator, guardian, or other person who, under the law of another state or a court order, may consent for the child; additionally, I certify that I do not have knowledge of any express refusals or withdrawn authorizations of consent and have not been told not to give consent for the child.
I understand that any Protected Health Information (“PHI”) I provide Immunogenomics Vaccine Clinic will only be used or disclosed by Immunogenomics in accordance with Immunogenomics’s Health Insurance Portability and Accountability Act (“HIPAA”) Notice of Privacy Practices. By signing below, I acknowledge receipt of such HIPAA Notices of Privacy Practices and consent to the uses and disclosures of PHI described therein. While Immunogenomics reserves the right to not do so, I consent to Immunogenomics reporting my immunization information to State immunization Registry. Should Immunogenomics elect to report my immunization history to the Texas central immunization registry, ImmTrac, I further understand that my immunization information may be accessed by other healthcare providers, educators, public health representatives, state agencies, and certain insurance payers. I further authorize IMMUNOGENOMICS to (1) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment or otherwise. (2) submit a claim to my insurer for the below requested items and services, and (3) request payment of authorized benefit be made on my behalf to IMMUNOGENOMICS with requested items respect to the below requested items and services. I further agree to be fully financially responsible for any co-sharing amounts, including copays, co-insurance, and deductibles, for the requested items and services as well as for any requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, if IMMUNOGENOMICS invoices me after the time of services, upon receipt of such invoice. Please note: for non-prescription insurance (I.e. medical/health insurance), your insurance will notify you and IMMUNOGENOMICS the exact copay/coinsurance amount due once they receive and process the claim. You may receive an invoice for any amounts due, up to and including the total amount of the claim.
NOT A SUBSTITUTE FOR A PHYSICIAN
I understand that IMMUNOGENOMICS Vaccine Clinic representatives may not be physicians trained to diagnose and treat medical problems. I acknowledge that the administration of Services does not constitute, and should not be interpreted as, medical advice or opinions substituting for the advice of a physician. I understand that the administration of Services does not create a doctor-patient relationship between myself and IMMUNOGENOMICS. I agree to consult a physician if I require medical services or advice at any time.
RELEASE, IMDEMNITY AND DISCLAIMER
I understand that it is not possible to predict all possible side effects or complications associated receiving vaccine. I understand the risks and benefits associated with the below vaccine and have received, read and/or had explained to me Vaccine Information Statements on the vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I additionally acknowledge that I have received a copy of the IMMUNOGENOMICS notice of privacy statement. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 to 30 minutes after administration for observation by the administering health care provider. I understand that in the course of the requested vaccine administration, an IMMUNOGENOMICS representative could possibly be exposed to my blood or bodily fluids. In such event, I agree to review and execute the “IMMUNOGENOMICS Post-exposure Consent for Testing” form.
On behalf of myself, my heirs, and personal representatives, I further WAIVE, RELEASE, and AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS (including for costs and attorney’s fees) IMMUNOGENOMICS its staff, agents, employees and corporate affiliates from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of Services listed below, even should such damages or losses result from IMMUNOGENOMICS’s negligence.