• Infant/Child RSV Immunization Request

    Infant/Child RSV Immunization Request

    MORGAN COUNTY HEALTH DEPARTMENT

  • NOTICE OF VACCINE ELIGIBILITY LIMITATION

    Morgan County Health Department offers RSV immunization(s) for VFC eligible infants/children only.

    What does this mean for you?

    MCHD is able to provide RSV immunization services for:

    • Infants/children eligible for Health benefits from Illinois Medicaid, including Managed Care organizations.
    • Uninsured infants/children

    We are NOT able to provide RSV immunizations to infants/children with private or commercial health insurance (example: infant/child insured through a parent/guardian's employer group plan).

    Parents or guardians of infants/children with private insurance should contact their pediatrician or medical provider to schedule this service.

  • DATE OF BIRTH*
     / /
  • SEX ASSIGNED AT BIRTH*
  • Format: (000) 000-0000.
  • DO THIS INFANT/CHILD HAVE HISPANIC OR LATINX ETHNIC HERITAGE?*
  • Does the person to be vaccinated have health insurance?*

  • Some individuals without comprehensive health insurance may qualify for vaccine assistance*.

    For more information please call 217-245-5111 or speak with a member of our staff on the day of the scheduled appointment.

    Fee(s) due at time of service. Payable via cash, check or charge (Discover, Mastercard or Visa). We are unable to process card payments for HSA/FSA accounts. Card payments subject to a 2.65% or $3 processing fee, whichever is greater.

    *Terms apply. Vaccines subject to availability. Any/all applicable fees due at time of service.

  • Appointment*
  • Does the infant/child to be immunized have any allergies to medication, food, an immunization component or latex?*
  • Does the infant/child to be immunized have a bleeding disorder?*
  • Did the birth mother/parent of this infant/child receive a dose of RSV vaccine during pregnancy?*
  • Has this infant/child ever received a dose of Palivizumab (SYNAGIS)*?*

  • By signing this form you indicate that you:

    • Request that the immunization be administered to the infant/child named above for whom I am authorized to make this request.
    • Will have read or have had explained the information in the Immunization Information Statement (IIS) prior to administration.
    • Will have had the chance to ask questions that were answered to your satisfaction prior to vaccine administration.
    • Understand the benefits and risks of the immunization products and ask that those agreed upon by myself be given to the infant/child for whom I am authorized to make this request.
    • Understand immunization administration information will be recorded in the state of Illinois Immunization Registry (I-CARE)

    General Consent & Financial Agreement: I consent to the rendering of an examination and treatment by Morgan County Health Department employees and their contractors.  I accept the risks involved with the nature and purposes for all procedures associated with my care and treatment and understand, I have the opportunity to ask questions and have them answered to my satisfaction. I understand that any and all services are rendered on a voluntary basis; I also have the right to refuse or stop services at any time. I understand that electronic medical records are maintained and secured utilizing Custom Data Processing (CDP). The system collects client data and visit information and calculates billing on behalf of the Morgan County Health Department.  I authorize the Morgan County Health Department to release information from my medical record to any health care provider participating in any way in the care of the patient and to any person or entity which is or may be liable for all or part of the charges for services received.  I understand that following release of medical records or information, the Morgan County Health Department will no longer be responsible for the confidentiality of any documents released in accordance with this authorization If I am eligible for any Commercial Insurance and/or Medicaid coverage, I agree to notify the Morgan County Health Department of the nature and extent of my coverage at the time of signing this document.  I hereby authorize payment of benefits by any third party payer directly to the Morgan County Health Department for services rendered. By signing below, I acknowledge that I was offered a copy of the Morgan County Health Department Notice of Privacy Practices, HIPAA.  I understand that I should read it carefully.  In consideration of the services provided, the undersigned agrees to pay all charges of the Morgan County Health Department if applicable.  Each bill is due and payable upon presentation (at time of service) or mailing of same to either the patient and/or the guarantor, unless other payment arrangements are made.  I CERTIFY THAT I UNDERSTAND AND AGREE TO THE PROVISIONS CONTAINED WITHIN THIS AGREEMENT. I voluntarily give permission for treatment by the Morgan County Health Department.

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