Red Bank Primary School Clinic, FLU & Covid Vaccine Form

Clinic Organized by:

Marlboro Medical Arts Pharmacy

479 County Road 520, A-102

Marlboro, NJ 07746

(732)-946-1600

www.MarlboroRxNJ.com

Ritesh Shah Charitable Pharmacy

226 Shrewsbury Avenue

Red Bank, NJ 07701

(732)-784-8999

www.rscprx.org

Red Bank Primary School Clinic

FLU & COVID Vaccine Form.

Please fill out form below, sign & submit to secure your appointment.

Clinic Address: 222 River Street, Red Bank, NJ 07701

SELECT CLINIC DATE

Vaccine Clinic Site

Do you have insurance?*

Flu vaccine (Afluria: age 6months and older)High Dose Flu vaccine (Fluad :age 65 years and older)

Covid Moderna (Spikevax) (Age 12 years & older)Covid Pfizer (Comirnaty) (Age 12 years & older)Pediatric COVID Pfizer (5-11 years)Pediatric COVID Moderna (3-11 years)

Name*

First NameLast Name

Date of Birth*

Date

MaleFemale

Address*

Address

Street Address Line 2

CityState

Zip

Phone*

Format: (000) 000-0000.

Email*

example@example.com

List any known Allergies

List any known Medical Conditions

YesNo

HIGH-DOSE Flu VaccineRegular Flu Vaccine

YesNo

Enter your Medicare Part-B number here (From Red, White & Blue Card)

Enter your Medicare ADVANTAGE Plan Name and ID Number here

Insurance Name

Rx BIN# (it is a 6 digit number, starts with either 0 or 6)

Rx PCN (usually found next to RxBIN #)

Member ID #

Rx Group# or Group number

Upload front of the insurance card (USE WHITE BACKGROUND)*

Upload YOUR PICTURE ID (DRIVER LICENSE) (USE WHITE BACKGROUND)*

Primary Care Physician

Phone

Format: (000) 000-0000.

Have you had Any Vaccine(s) in the past 4 weeks? If Yes, what was given and when:

YesNo

Yes, please list in the other section belowNoOther

Yes, please list in the other section belowNoDon't knowOther

YesNo

Please read ALL of the following 3 statements, if consent is given, please sign and date below.

I have been provided with the Vaccine Information Sheet (VIS) and/or been provided with information regarding to the vaccine I am receiving.
I understand all the benefits and risks of the vaccine and have had the chance to ask questions regarding it. I voluntarily assume full responsibility for any reactions that may result.
I request the vaccine be given to me and authorize and direct Marlboro Medical Arts Pharmacy to use or disclose my health information during the term of this Authorization to the physician responsible for this protocol of specific health information of people vaccinated by this provider (standing order practitioner), my Primary Care Physician (PCP), my insurance plan and/or state federal registries, where required for purposes of treatment, payment or other health care operations. This only allows this provider to disclose the following medical records: only documents related to the vaccination received today. This authorization will remain in effect until my health care provider discloses my health information to the recipient identified above; my health care provider cannot guarantee that the recipient will not disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. I understand that I may refuse or revoke this Authorization at any time. I understand that this authorization will remain in effect until the term of this authorization expires or I provide a written notice of revocation to my health care provider. The revocation will be effective immediately upon my health care provider's receipt of my written notice.

HIPAA Privacy Information and Medical Records

I have acknowledged that I have received the provider's Inc Notice of Privacy Practices which may be provided at my request.
For Medicare, Medicaid, or Insurance Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct.
I authorize the release of all records to act on this request and I request that payment of benefits be made on my behalf.

Date*

Date

Signature*