Medical Insurance:
(Please type n/a if not applicable)
Prescription Drug Plan:
(Please type n/a if not applicable)
Note: MBI is required for all patients age 65 and older, or Medicare eligible. please bring the Red, White, and Blue card.
*If uninsured, you must check the box below to attest that the following information is true and accurate:
Example: a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?
CONSENT FOR SERVICES: I have beenprovidedwiththeVaccineInformation
Sheet(s) or patient fact sheet corresponding to the vaccine(s) 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 voluntarily assume full
responsibility for any reactions that may result.IunderstandthatIshould
remaining the vaccine administration area for 15 minutes after the vaccination to
be monitored for any potential adverse reactions. I understand if I experience
side effects that should do the following: call the pharmacy, contact the doctor, 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.
COVID-19 Program for Uninsured Patients is correct. I authorize the release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.
DISCLOSURE Of Records: I understand that A&D 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 A&D Pharmacy (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems, and hospitals, and/or state or federal registries, for purposes of treatment, payment or other healthcare operations (such as administration or quality assurance). I also understand that A&D Pharmacy will use and disclose my health information as set forth in the A&D Pharmacy Notice of Privacy Practices (a copy is available in-store, online, or by requesting a paper copy from the pharmacy).
AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize A&D Pharmacy® to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA is accurate.