If you are on Medicare, please provide the following:Medicare Beneficiary ID blanks Social Security Number blank
If you are uninsured and receiving a Covid-19 Vaccine please provide one of the following:Social Security Number blanks Driver's License Number
If you are on a commercial insurance plan, please provide us with a picture of the front and back of your insurance card or bring your insurance card with you to your appointment.
Please help us bill your insurance for your vaccine by taking a picture of the front and back of your Medicare Card, Medicare Advantage Card, Commerical Insurance Card or Kancare Card. Alternatively, you can bring your card to your appointment.
By signing this form, I agree to be vaccinated today by El Dorado TrueCare Pharmacy. I have received and understand information about the vaccines designated above. I have had my questions answered to my satisfaction. I oauthorize the payment of medical benefits to the provider performing the service. If I have a copayment or the vaccine is not covered on my insurance, I will remit payment to El Dorado TrueCare Pharmacy.