Please note: We only have appointments available on Wednesdays for 1st doses starting on week of May 31st. Appointments will only be made up to 2 weeks in advance.
I acknowledge that I have read the COVID vaccine information on our website (www.poolesvillefamilypractice.com/covidvaccine), including the Moderna Emergency Use Authorization, CDC COVID Vaccine Facts, and the CDC What to Expect After your COVID Vaccine documents.
Sorry but you are not eligible for the vaccine based on the Maryland state vaccine phase. We do encourage you to get the vaccine once you are in the eligible phase.
Please contact our office at 301-972-7600 or email us at email@example.com if you need a 2nd dose of of the Moderna vaccine and your 1st dose was given at a different location.
The CDC recommends that you not get the COVID vaccine within 14 days of any other vaccine. You may restart the screening process and request the COVID vaccine once it has been more than 14 days since your other type of vaccine.
If it has been less than 14 days since your COVID positive test OR if you still have symptoms from COVID, we recommend you wait until you met both of these criteria prior to requesting a COVID vaccine.
The CDC recommends waiting at least 90 days after receiving passive antibody therapy to start the COVID vaccine series. You may request a COVID vaccine after it has been over 90 days since your treatment.
Social Security (SSN) or Tax ID Number (TIN): Your Social Security or Tax ID number is needed because you indicated that you do not have insurance. We will submit for vaccine administration reimbursement through the HRSA uninsured program. This program requires us to have the person's Social Security or Tax ID number. If you do not have a Social Security or Tax ID number, you can enter your Driver's license or other state issued ID number.
PLEASE BRING YOUR PHOTO ID TO YOUR APPOINTMENT.
A federal law known as HIPAA (the Health Insurance Portability and Accountability Act) requires that medical practices and other medical providers explain to you the rules governing the privacy of your medical records. We comply with HIPAA and all local/state health privacy regulations. If you would like a copy of our official HIPAA policy it is available at the front desk or our website (poolesvillefamilypractice.com ).
Poolesville Family Practice is only contracted with Medicare (and no other private insurer)
I understand that Poolesville Family Practice is not contracted with my insurance company (except Medicare). Poolesville Family Practice will submit the bill for your vaccine administration to your insurance, but you are NOT responsible for any out of pocket expenses. If you do not have insurance, we are offering the vaccine without any charges to you.
Prescription History Access:
In order to better care for you, our doctors and staff may need to access your prescription medication history. By signing this document you give us permission to have access to your electronic prescription history.
Maryland Health Information Exchange:
We have chosen to participate in the Chesapeake Regional Information System for our Patients, Inc. (CRISP), a statewide health information exchange. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and prevent access of your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org.
As required by the State of Maryland, we will submit your vaccine records from our office to Immunet. ImmuNet is Maryland’s Immunization Information System (IIS), a confidential and secure database that is HIPAA compliant. It stores an individual’s vaccination records, and is a web-based tool for healthcare providers and schools to keep their patients/students vaccinated on time and avoid under or over vaccination.
I agree to all of the above statements and have had all of my questions regarding the above statements answered to my satisfaction.