RELEASE AND ASSIGNMENT:
· I have read or had explained to me the Vaccine Recipient Emergency Use Authorization (EUA) Fact Sheet for COVID-19 vaccine risks and benefits. To read the Vaccine Recipient Emergency Use Authorization Fact Sheet for each vaccine visit the website https://www.cdc.gov/vaccines/covid-19/eua/index.html to view current EUA: or you may also visit the Local Health Unit or private provider to receive a printed copy of the EUA Fact Sheet.
· I give consent to this COVID-19 provider/staff for the individual named above to be vaccinated with COVID-19 vaccine.
· I hereby acknowledge that I have reviewed a copy of the Provider’s Privacy Notice.
· I understand that information about this COVID-19 vaccination will be included in (WebIZ) Arkansas Immunization Information System.
TO MY INSURANCE CARRIERS:
· I authorize the release of any medical information necessary to process my insurance claim(s).
· I authorize and request payment of medical benefits directly to this COVID-19 Provider.
· I agree that the authorization will cover all medical services rendered until I revoke the authorization.
· I agree that the photocopy of this form may be used instead of the original.
CONSENT TO NOTIFY:
I consent that Southern Pharmacy may contact me via email and/or sms message using the information provided. Contact information may include COVID-19 vaccine availability, COVID-19 vaccine appointment reminders, and other healthcare information.
PLEASE CLICK SUBMIT TO VERIFY CONSENT