Consent for services: I have been provided with the Vaccine Information Sheets or patient fact sheet corresponding to the vaccine that I am receiving. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call pharmacy, contact doctor, call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make the request. All VIS forms are available in the pharmacy and you may access all forms with your cell phone as well.
Authorization to request payment: I do hereby authorize Horsham Square Pharmacy to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or my prescription insurance. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.
Disclosure of records: I understand that Horsham Square Pharmacy may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at Horsham Square Pharmacy, my Primacy Care Physician, my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or understand that Horsham Square Pharmacy will use and disclose my health information asset forth in their Notice of Privacy Practices (copy available in store).
Dr. James Mahoney has authorizations for all vaccines given by Horsham Square Pharmacy. The master copy is located in the pharmacy.