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