BTSF Immunization Consent and Registration Form

Attention!!!

Before completing this form, please note that if you have private health insurance 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. If your child is uninsured or has Missouri Medicaid, they will be eligible to receive vaccine through the Vaccines for Children program.

Immunization Consent & Registration Form
Patient Information
Today's Date*

MonthDayYear
Date
Patient Name*
First Last
Patient Date of Birth*

MonthDayYear
Date
Address*

Street Address (Include Apartment Number if Applicable)

City

StatePostal/Zip Code

County of Residence (i.e., Platte, Clay, Jackson)
Home Phone Number*
Please enter a valid phone number. If no home phone number, please enter your cell phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number. If no cell phone number, please enter your home phone number.Format: (000) 000-0000.
FemaleMale
American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
Hispanic/LatinoNot Hispanic/LatinoOther
YesNo
Please list all allergies
Please list all allergic reactions
Insurance Information
MedicaidUninsuredUnderinsuredNative American/Alaskan NativeMedicarePrivate Insurance
Medicaid/Medicare Number
Private Insurance Information
Name of Primary Health Insurance
Name of Policy Holder
Policy Holder Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Address
Address (Apartment Number if Applicable), City, State, Zip Code
Policy or Member Numbers
Group Number
Customer Service or Provider Phone Number on back of the Insurance Card
Please enter a valid phone number.Format: (000) 000-0000.
Please upload a front and back copy of your insurance card

Cancelof
Authorization and Consent
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.
Signature of Patient, Parent, or Legal Guardian (Use mouse, stylus, or finger to sign)*

Clear
Print Name*
First and Last
Date Signed*

MonthDayYear
Date
Relationship to Patient*
Self, Parent, Legal Guardian, etc.
We're sorry, but we only accept Blue Cross Blue Shield, Cigna, and United Healthcare insurances. Please reach out to your child's primary care provider to sign them up for their immunizations. Thanks for allowing the Platte County Health Department for being a part of your family's health.
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Immunization Consent & Registration Form

Patient Information

Insurance Information

Private Insurance Information

Authorization and Consent