If applicable on insurance card, please provide your RX BIN, RX GROUP, and RX PCN numbers.
I consent to receiving the flu vaccine from Times Pharmacy.
I understand that I am giving Times permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Times to process my insurance claims with respect to the vaccination.
I understand that if my insurance does not pay for the servicesrendered on this form, I am responsible for payment.
I, for myself, my heirs, executors and assigns hereby release Times and itsdivisions and affiliates and their respective officers, directors, employees, agents and representatives from any and all claims arising out of or in connection with this vaccination.
I also acknowledge that I received a copy of the Vaccine Information Statement (VIS)for the vaccine stated below and that I understand the benefits and risks associated with the described vaccine. The VIS will be sent to the email address provided.