Consent to Treat:
AUTHORIZATION FOR TREATMENT/FINANCIAL RESPONSIBILITY: I authorize the Physician(s) or his/her designee(s), in charge of my or the recipient's (named above) care to administer any treatment including medication(s) or vaccine(s) as deemed necessary or advisable in the diagnosis and treatment of any conditions related to me or the recipient. This authorization is valid and in effect until such time I withdraw it in writing or in person.
JOINT NOTICE OF PRIVACY PRACTICES: I understand that this notice is required to be signed one time each year and that Tribal Health uses this combined form to ensure recipient receives information about their rights.
I have read, or have had explained to me, the Authorization for Treatment and Financial Responsibility Statement and Joint Noitice of Privacy Practices. I acknowledge receiving a copy of each statement. I understand the contents and by signing; I agree to be legally bound by each document. I understand that this signature will be returned to Tribal Health and entered into my legal electronic health record.
I agree to be responsible for any financial cost-sharing amounts, including copays, coinsurance, and other deductibles including those which are not covered by my insurance benefits.
ImMTrax Consent:
I have read the influenza and/or COVID-19 vaccination information statement(s) and have had the opportunity to ask questions. I understand the benefits and risks of influenza and/or COVID-19 vaccination(s) as described. I request that the vaccine(s) be given to me or to the person or child listed above for who I am authorized to sign.
I authorize this Health Department to collect and enter immunization records for my child, myself, or any person that I am authorized to sign for into the Department of Public Health and Human Services' Immunization Registry (ImMTrax). ImMTrax is a confidential, computer system that contains immunization records. I understand that the information in the registry may be released to a public health agency, as well as, my health care providers to assist in medical care and treatment. In addition, information may be released to childcare facilities and schools in which my child is enrolled to comply with state immunization requirements. I understand that I can revoke this authorization and have my record removed at any time by contacting my local health department.