• Randolph County Health Department

    COVID-19 Immunization/HIPAA Consent

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Sex*
  • Ethnicity*
  • Race*

  • I have been given a copy of, and have read or had explained to me, the information in the "Vaccine Information Statement(s)," where applicable for the COVID-19 vaccine. I have had a chance to ask questions and have had them answered to my satisfaction. I understand the benefits and risks of the requested vaccine(s I understand the known and potential risks and benefits of the COVID-19 vaccine. My decision to receive this vaccine is voluntary, and I may refuse vaccination. I have signed below based on the recommendations and ask that the vaccinations I approve be given to me or to the person named above, for whom I am authorized pursuant to Section 431.058, RSMo, to make this request.

    By signing this form, I am requesting that payment for authorized Medicare/Medicaid/MC+/Private Insurance benefits be made on my behalf to the Randolph County Health Department for any services furnished by their professional staff. I authorize the Randolph County Health Department to record and report my vaccination as required by public health authorities. I authorize the release of any information needed to determine these benefits or the benefits payable for related services.

    Health Insurance Portability And Accountability Act (HIPAA)

    A copy of the Randolph County Health Department's Notice of Privacy Practices has been made available to me. I acknowledge receipt of this notice by signing this form on the line below. A copy of this notice will be provided to me at any time upon my request, and/or I may obtain a current copy of the Notice of Privacy at www.randolphcountyhealth.org. The Randolph County Health Department agrees to abide by our most current copy of the Notice of Privacy. Eligibility Status: MedicaidNo Health InsuranceAmerican Indian/Alaska Native Underinsured (FQHC/RHC) Not VFC EligiblePrivate Insurance

  • Eligibility Status*
  • Insured DOB
     - -

  • I self-attest that I meet the current CDC and State of Missouri eligibility requirements for receiving the COVID-19 vaccine. I confirm I am within the age group authorized for vaccination. I confirm that I meet any other eligibility criteria (e.g. risk status, health condition, or updated vaccine guidance Signature (Patient or Parent/Guardian):

  • Date*
     / /
  • Are you feeling sick today*
  • Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something?*
  • Have you ever had a serious reaction after any vaccination or injectable medication?*
  • Do you have any of the following:  a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, a cochlear implant, or a spinal fluid leak?*
  • Are you on long-term aspirin therapy?*
  • Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
  • In the past 6 months, have you taken medications that affect your immune system, such as prednisone, other steroids, anticancer drugs, or drugs for the treatment of rheumatoid arthritis? Or do you have Crohn’s disease, psoriasis, or have had radiation treatments?*
  • Have you had a seizure or a brain or other nervous system problem?*
  • Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?*
  • In the past year, have you received immune (gamma) globulin, blood/blood products, or an antiviral drug?*
  • Are you breastfeeding or pregnant?*
  • Are you anxious about getting a shot today?*
  • Do you have a bleeding disorder, or are you taking a blood thinner?*
  • Have you been diagnosed with Alpha-gal syndrome (AGS)?*
  • Have you had any vaccinations within the past 4 weeks?*
  • Have you ever felt dizzy or faint before, during, or after a shot?*
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