Please read the following statements and sign below. I have read or have had explained the information provided about the vaccine I am about to receive. I have received and read a Vaccine Information Statement. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of vaccination and ask that the vaccine be given to me or to the person named above for whom I am authorized to make this request. Medicare, I do hereby authorize Suncrest Pharmacy to release information and request payment. I certify that the information given by me in apply for payment under Medicare is correct. I authorize release of all records to act on this request. I request that the payment of authorized benefits be made on my behalf. Disclosure of Records.

I understand that Suncrest Pharmacy may be required to or may voluntary disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at or through Suncrest Pharmacy (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems/hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (administration/quality assurance I also understand that Suncrest Pharmacy will use and disclose my health information as set forth in the Suncrest Pharmacy Privacy Practices.

Vaccine Clinics: if I am receiving a vaccine through a vaccine clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator.