CONSENT: I authorize payment for approved Medical Benefits be made on my behalf to LECOM Center for Health and Aging for services furnished me by the physician/supplier. I consent to the use and/or disclosure of my health information consistent with LECOM Center for Health and Aging Privacy Practice Policies of which a copy has been made available to me. I have read or had explained the above information. I hereby release the LECOM Center for Health and Aging and its agents from any and all claims of damage, loss, or liability arising out of the administration of this vaccine. I consent to be vaccinated or give consent for vaccination for the person named for whom I am legally authorized to give this consent.