STOP Please only fill out this form if you have an appointment
Information collected on this form will be used to document that you have received vaccine(s). Information about your vaccine(s) may be shared through the Minnesota Immunization Information Connection (MIIC) with other health care providers, schools, health departments, and others authorized under law to receive it. If you have any questions, please ask your doctor or other health care provider. If you have questions about MIIC, refer to MIIC and the Public (www.health.state.mn.us/people/immunize/miic/public.html) or call 1-800-657-3970.
Assignment of benefits and responsibilities for payment
This lets us bill your health plan or company and to receive payment directly. There is no cost for the COVID-19 vaccine, Although we will bill your insurance company for an administrative fee.
I authorize this health provider to bill my health plan or other payers on my behalf, and to receive payment of authorized benefits.
Contact information – person being vaccinated
Payment information Bring a copy of your insurance card with you!
Policy holder, if different from the person getting vaccinated:
By signing below, I understand, recognize, approve, and agree that:
I have received and read or had explained to me the Emergency Use Authorization Fact Sheet for the following COVID-19 vaccine: [Insert name of vaccine product below].
I have had the chance to ask questions which were answered to my satisfaction, and I understand the benefits and risks of the COVID-19 vaccine as described.
I agree to receive the COVID-19 vaccine for myself or for the person named above.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Are you the correct age to receive the COVID-19 vaccine?
PATIENT/PARENT DO NOT WRITE BELOW THIS LINE
Your information will be encrypted.
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