RSV Beyfortus Scheduling and Consent Form

RSV Beyfortus Scheduling and Consent Form

Please fill out this form if you wish for you infant to get the RSV antibody shot. We will call you to confirm an appointment time and date. Thank you!
Infant's Name:*
Infant's DOB:*

MonthDayYear
Insurance Company*
Parent/Legal Guardian/Signatory Name*
Did this infant's mother received an RSV shot (Abrysvo) during her pregnancy?*
The best days and times for me are the following (check all that apply). If none of these work, please call our office and we'll work with you!

Tuesday MorningsThursday MorningsWednesday MorningsThursday AfternoonsWednesday Afternoons
Best contact number to confirm appointment:
Please enter a valid phone number.
CDC Beyfortus Information Statement
As the parent/guardian of the patient listed above, I desire the Beyfortus Monoclonal Antibody injection for my child. I understand that at this time it appears my insurance will cover this injection. The total amount billed to insurance will be approximately $650. This early eligibility determination is not a guarantee of payment from insurance. If my insurance company DENIES payment of the injection for any reason I understand that I will be personally responsible for payment for this injection. Should my insurance not cover the service, I understand that I will be charged $600 (self-pay discount). Should my insurance apply any or all of this visit to my deductible or any other cost sharing arrangement (copays, co-insurance, etc.), I understand that I will be responsible for whatever that amount is and that Roadrunner Pediatrics cannot change this amount as this is determined by my insurance company and coverage with them.
Patient/Parent/Guardian Signature

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Date Signed*

MonthDayYear
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