Attention!!!

Before completing this form, please note that if you have private health insurance that we ONLY accept the following insurances: Blue Cross Blue Shield, United Healthcare, and Cigna. If you have a different type of private insurance, please reach out to your child's primary care provider to schedule their immunization appointment.

Personal Financial Responsibility: By signing this form, and in return for the services rendered by the Platte County Health Department (PCHD), I am personally responsible for all fees not paid by any third party on my behalf.

Assignment of Insurance Benefits: I hereby assign all my interest and rights to all insurance benefits otherwise payable to me from any policy to PCHD. I agree that PCHD may disclose any portion of my medical, financial, or personal information to any person or organization requiring such information as a condition of paying, receiving payment for, or justifying payment for my health care or the health care of one for whom I am responsible. I further authorize payment of all insurance benefits, otherwise payable to me, for all treatment provided directly to PCHD. I understand that I am responsible for any amount not covered by insurance.

My signature indicates that I have reviewed a copy of the “Notices of Privacy Practices” and have read the Emergency Use Authorization (EUA) Fact Sheet for REcipients/Caregivers and/or the Vaccine Information Statement (VIS) for the vaccine(s) that I am requesting be given to the person named on the form.