THERE IS NO COST TO YOU. I (the patient) hereby authorize Kim A. Kelly MD, PC to apply for benefits on my behalf for all services rendered with my insurance. I (the patient) certify the information provided regarding my insurance coverage is correct. I (the patient) further authorize the release of any and all information necessary for my insurance company to determine benefits for services rendered. I (the patient) request payment of authorized benefits be made payable to Kim A. Kelly MD, PC on my behalf.
If I (the patient) do not have insurance, I (the patient) have truthfully indicated above and will not be responsible for the cost. I (the patient) acknowledge that if I (the patient) do not have insurance, my information will be submitted to the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) so that Kim A. Kelly MD, PC will be funded for the cost of my immunization administration.
If I (the patient) have Medicare, Medicaid or other government insurance, I (the patient) authorize the release of my medical or other information necessary to process this claim. I (the patient) also request payment of government benefits either to myself or to the party who accepts assignment.
I (the patient or parent/guardian if patient is under 18 years of age) have read the above and have provided Kim A. Kelly MD, PC with true and correct information and will notify Kim A. Kelly MD, PC of any changes in health insurance coverage.
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which was provided to me at the time of registration. I have had a chance to ask questions that were answered to my satisfaction.
I agree to WAIT near the clinic location for 15 minutes after receiving the vaccine. If I or my child have previously had a severe allergic reaction to a vaccine or injectable medication, I agree to WAIT near the clinic location for 30 minutes after receiving the vaccine.
I understand that the COVID-19 vaccine is a two-part vaccine series. By signing this consent, I am agreeing that I or my child will receive the first and second part of the vaccine series.
I understand that the vaccination is being given by Kim A. Kelly MD, PC. The owner and/or operator of this site, their affiliates, officers, directors, employees and agents expressly disclaim any responsibility for the vaccination. My consent is given in light of this knowledge, and in consideration of Kim A. Kelly MD, PC giving the COVID-19 vaccine. I, for myself and my heirs and family members, administrators, trustees, executors, assigns and successors in interest do hereby agree to release and hold harmless Kim A. Kelly MD, PC, its subsidiaries, divisions, affiliates, successors, assigns, officers, trustees, employees, volunteers and agents from and against any and all demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including, without limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of, directly or indirectly, my receipt of this COVID-19 vaccine.
I further understand that my provider is required to submit COVID-19 vaccine administration data to ImmuNet, Maryland's Immunization Information System. I was also offered a copy of the Kim A. Kelly MD, PC Notice of Privacy Practices at the time of registration.
Notice of Privacy Practices