CONSENT FOR SERVICES: I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) or EUA Moderna COVID-19 vaccine that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I have voluntarily assumed full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for a minimum of 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call the pharmacy, contact you doctor and call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.
AUTHORIZATION TO REQUEST PAYMENT: I do herby authorize The Pharmacy to release information and request payment.
I certify that the information given by me in applying for payment under Medicare or Medicaid, private insurance, or the HRSA COVID-19 program for Uninsured Patients, is correct. I authorized benefits be made on my behalf.
DISCLOSURE OF RECORDS: I understand that The Pharmacy may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated at The Pharmacy or clinics (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries such as Massachusetts vaccine registry (MIIS), for purposes of treatment, payment, or other health care operations (such as administration or quality assurance). I also understand that The Pharmacy will use and disclose my health information as set forth in the Notice of Privacy Practices (copy is available in-store, online or by requesting a paper copy from the pharmacy).
AUTHORIZATION: I do hereby consent The Pharmacy to submit vaccination data to state and federal vaccination registries.