For those who received at least one dose of Pfizer or Moderna:
For those who received Janssen / Johnson & Johnson:
Which dose of COVID-19 vaccine will this be?
INSURANCE INFORMATION: Fill the appropriate category.
MEDICARE PART B
No Insurance: To have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please provide one of the following:
I attest that I meet one or more of the criteria listed above.