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  • NYS COVID-19 Vaccine Priority Groups 1A, 1B, and 1C Application Form

    Any information you submit via this HIPAA compliant form is encrypted, kept strictly confidential, and will be used only for the purposes of determining vaccine eligibility and scheduling.
  • Demographics

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  • PLEASE NOTE: If you are not already a patient of Refuah, you must also register as a new patient here https://refuahhealth.org/new2refuah/ before you can be added to our waiting list.

  • Proof of Eligibility - Only New York State (NYS) residents are eligible to receive NYS vaccine.

    This requirement is waived for individuals who work in NYS and qualify to receive the vaccine under groups 1A or 1B due to their employment.
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  • Clinical Screen

  • Attestation

  • The mandatory NY State COVID-19 Vaccine Form vaccineform.health.ny.gov must be completed PRIOR to vaccination. It includes a self-attestation regarding eligibility. 

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