The Public Readiness and Emergency Preparedness Act (PREP Act) authorizes the CICP to provide benefits to certain individuals or estates of individuals who sustain a covered serious physical injury as the direct result of the administration or use of the covered countermeasures. The CICP can also provide benefits to certain survivors of individuals who die as a direct result of the administration or use of covered countermeasures identified in a PREP Act declaration. The PREP Act declaration for medical countermeasures against COVID-19 states that the covered countermeasures are any antiviral medication, any other drug, any biologic, any diagnostic, any other device, or any vaccine used to treat, diagnose, cure, prevent, or mitigate COVID-19, the transmission of SARS-CoV–2 or a virus mutating from SARS-CoV-2, or any device used in the administration of and all components and constituent materials of any such product. Information about the CICP and filing a claim is available by calling 1-855-266-2427 or visiting http://www.hrsa.gov/cicp/.
Authorization to Request Payment: I do hereby authorize Schroeder Drugs to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf. Disclosure of Records: I understand that Schroeder Drugs may be required to or may voluntarily disclose my health information to my Primary Care Physician (if I have one), my insurance plan, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance
Acknowledgement of Notice of Privacy Practices: I have received a Notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by Schroeder Drugs and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Consent: I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) and V-Safe, a copy of which I was provided with this Consent and Release. I have had a chance to ask questions and had them answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the vaccine currently due for which I have signed below 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. ShowMeVax Reporting: This notification is being provided pursuant to § 338.010.13, RSMo. I understand and acknowledge the administration of this vaccine will be entered into the ShowMeVax system administered by the Missouri Department of Health and Senior Services unless I indicate otherwise below: