I acknowledge that the Vaccine Information Statement(s) will be e-mailed automatically to the e-mial address I provided. 

Consent to Treat: I authorize Hill County Health Department (HCHD) to administer treatment as deemed necessary for care of the patient named above. I certify that I am the parent or legal guardian of the patient. I also certify that no guarantee or assurance has been made as to the results that may be obtained from the treatment.
Assignment of Benefits: All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. The patient/parent/responsible party is responsible for any unpaid balances. Co-payments will be made at the time of service. I request that payment of authorized Medicare, Medicaid or Other insurance company benefits be made to HCHD for any services furnished to me by HCHD. Regulations pertaining to Medicare and Medicaid assignment of both benefits apply. My signature indicates all information provided is true and correct.
Consent for Inclusion in MT's Statewide Immunization Information System (IIS): I authorize HCHD to collect and enter my or my child's immunization records into the Department of Public Health and Human Services' IIS. The IIS is a confidential, computer system that contains immunization records. I understand that information in the registry may be released to the public health agency as well as my or my child's health care providers to assist in my or my child's medical care and treatment. In addition, information may be released to child care facilities and schools in which my child is enrolled to comply with state immunization requirements. I understand that I can revoke this authorization and have my or my child's record removed at any time by contacting my local health department.