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.
Patient’s name:
Address:
Policy holder, if different from the person getting vaccinated:
By signing below, I understand, recognize, approve, and agree that:
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.