BEYFORTUS AGREEMENT FORM

Patient Information:

Health Insurance Information:

We hereby agree to and understand the following:

1. Vaccine Expense:

We understand that our child will receive Beyfortus, the RSV Monoclonal Antibody shot, today. We understand the risks and benefits associated with this shot.

2. Deductible Application:

We acknowledge that our health insurance policy includes a deductible provision, which may apply to the cost of vaccines.

3. Authorization to Charge Credit Card:

We hereby authorize DuPage Pediatrics to securely keep our credit card information on file.

4. Charge for Vaccine Costs Applied Toward Deductible:

In the event that the cost of the injection and/or the administration fee is applied toward our insurance policy deductible and/or is not fully covered by insurance, we authorize DuPage Pediatrics to charge our credit card on file for the outstanding amount.

This cost is an estimate and we understand that the allowable amount may be slightly higher or lower: BEYFORTUS: $700 per injection.

Please note if your child is 8 months or older and is high risk, your child will need two injections at $700. (totaling $1,400).

5. Appeal:

We understand that it will then be UP TO US to appeal this decision with our insurance carrier. If our insurance then agrees to pay DuPage Pediatrics for the cost of the injection, we understand that we will be refunded any overpaid amount only AFTER the insurance payment has been processed by DuPage Pediatrics.

6. Payment Responsibility:

We acknowledge that it is our responsibility to ensure that the credit card on file has sufficient funds available to cover any charges applied toward the deductible. We may terminate this authorization by providing written notice, but if we do not provide another form of payment we may be assessed late fees and finance charges.

By signing below, we acknowledge that we have read and understood the terms of this Agreement and agree to be bound by them.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.