• Vaccine Consent Form

    * Please fill out the required details below
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  • Insurance Information

    You may choose to upload the front and back of your insurance card, or enter the appropriate card information below. If you choose not insured, American Indian/Native Alaskan, or Underinsured, you child qualifies for VFC & no payment is reuqired, but donations are accepted. A $25 docnation is suggested if you do not have insurance or we are not able to bill your insurance. If you have insurance questions, please call us at 515-961-1074.

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  • Wellmark BC/BS or United Health Care Insurance Information

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  • Questions

    For patients to be vaccinated:  The following questions will help us determine if there is any reason we should not give your child an inactivated injectable influenza vaccination today.  If you answer “yes” to any question, it does not necessarily mean your child should not be vaccinated.  It just means additional questions must be asked.  If a question is not clear, please ask your healthcare provider to explain it.

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  • I have read, or have had explained to me, the information about influenza disease and the influenza vaccine.  I have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of influenza vaccination and request vaccination to be administered to me, or the above named for whom I am authorized to make this request.

    I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain right to privacy regarding my protected health information.  The Notice of Privacy Practice has been made available to me, which explains these rights. Warren County Health  Services Notice of Privacy Practice can be viewed online at: https://healthservices.warrencountyia.org/Policy_HIPAA.pdf . I authorize the release of medical or other information necessary to process billing claims.  I authorize Payer to pay provider directly and agree to pay any co-pay, deductible, or amount not paid by insurance.

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