• CHILD-TEEN VACCINE APPOINTMENT REQUEST

    CHILD-TEEN VACCINE APPOINTMENT REQUEST

    MORGAN COUNTY HEALTH DEPARTMENT
  • DATE OF BIRTH*
     / /
  • SEX ASSIGNED AT BIRTH*
  • Format: (000) 000-0000.
  • DOES THIS CHILD HAVE HISPANIC OR LATIN AMERICAN ETHNIC HERITAGE?*
  • Does this child/teen have health insurance?*

  • Children/teens without comprehensive health insurance may qualify for vaccine assistance*.

    For more information please call 217-245-111 or speak with a member of our staff on the day of your 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. Immunizations/vaccines subject to availability. Any/all applicable fees due at time of service.

  • Does this insurance pay for all ACIP recommended vaccines?
  • Is Morgan County Health Department and in-network provider for this insurance plan?
  • Which type(s) of health insurance does this child/teen have? (check all that apply)
  • Insured Person's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please provide valid proof of insurance for the person to be vaccinated. Submit a photo of the front side of your/their insurance card using either method below.

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  • Which services are you requesting for this child/teen? (check all that apply)*
  • Do you want your child/teen to receive all of the ACIP recommended immunizations at this visit?
  • Which immunizations are you requesting for your child/teen? (check all that apply)
  • Please select a date/time from the calendar below:*

  • Please be prepared to provide proof of insurance at your child's appointment.

    Uninsured and Under-insured children may qualify for vaccine assistance.

    • Services subject to vaccine availability

    • Pricing varies by service type

  • By signing this form you indicate that you:

    • Will have read or have had explained the information in the Vaccine Information Statement (VIS) about the vaccine(s) 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 vaccines and ask that those vaccines agreed upon by myself or my legal guarduan be given to me or the person for whom I am authorized to make this request.
    • Are aware some vaccines may contain the preservative Thimerosal
    • Understand vaccine 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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