2025-26 COVID Vaccine Eligibility Waiver
This form outlines the criteria for receiving the COVID vaccine at Family Care. For current patients with in-network insurances, payment will not be required at the time of service. For non-current patients, uninsured patients, or patients with out-of-network insurances, a $150 payment will be required at the time of service. Please complete the information below and sign to attest that you are eligible for vaccination and understand the risks associated with receiving the vaccine. This form is required for Family Care to administer the COVID vaccine and you will need to sign a separate billing waiver at your appointment.
Patient Name
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First Name
Last Name
Patient DOB
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Month
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Day
Year
Date
Patient Email
If patient would like copy of this waiver and the Vaccine Information Sheet.
Eligibility Criteria
All patients must confirm one of the following medical indications for vaccination.Respiratory disease: Asthma, COPD, cystic fibrosis, interstitial lung disease, etc.Metabolic & chronic diseases: Diabetes (type 1, type 2, gestational), obesity/overweight, chronic kidney/liver diseaseCardiovascular & cerebrovascular: Heart conditions (including congenital), strokeImmunocompromised & disorders: Cancer, HIV, primary immunodeficiency, transplant recipients, immunosuppressant therapyNeurologic & developmental: Down syndrome and other disabilities, dementia, Parkinson’s diseaseBehavioral & lifestyle factors: Mental health disorders, physical inactivity, smoking, substance use disordersOther conditions: Pregnancy, tuberculosis, sickle cell, thalassemia, etc.
Do you have a covered medical indication for vaccination?
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Yes
No
What is your covered indication for vaccination?
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Please Select
Respiratory Disease
Metabolic / Chronic Disease
Cardiovascular / Cerebrovascular Disease
Immunocompromised Disorders
Neurologic & Developomental Disorders
Behavioral & Lifestyle Factors
Other Conditions
This will be confirmed by your provider.
By signing, you acknowledge that you have received information regarding the risks and benefits associated with the COVID vaccine. You attest that you are eligibile to receive the vaccine and have had a chance to ask questions about the vaccine, and they were answered to your satisfaction. You understand the risks and benefits associated with the COVID vaccine and give consent to Family Care to administer the vaccine. If the vaccine is not covered by your insurance, you agree to make payment in full to Family Care.
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