COVID – ONE HANSON PHARMACY

Name

First

Last

Date of Birth

Address

Street Address City State / Province / Region Postal / Zip Code

Patient email

Patient’s phone#

Are you a resident ?

... of a Long Term Care facility.

... an employee/staff member.

No

Insurance Information: (For onsite clinics, please ensure a copy of the patient’s insurance card(s)

Medicare Fields: *Please type n/a if not applicable

Medicare Part A/B ID Number (MBI) Note: MBI is required for all patients age 65 and older, or Medicare eligible. Refer to your Medicare Red, White, and Blue card.

Medical Insurance: *Please type n/a if not applicable

Medical Insurance Provider

Cardholder ID #

*Group ID

*Payer ID

Is the patient the primary cardholder? If no, include primary cardholder’s DOB.

Yes

No

n/a

Prescription Insurance: *Please type n/a if not applicable

Prescription Insurance: Are you the primary cardholder? *If no, include primary cardholder’s DOB.

Yes

No

n/a

Prescription benefit plan name

Cardholder ID

Rx Group ID #

BIN

PCN

If uninsured, you must check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan.

Skip, I have insurance.

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration’s COVID-19 Program for Uninsured Patients, please provide either (a) a valid Social Security number, (b) state identification number and state of issuance, OR (c) a driver’s license number and the state of issuance.

Social Security Number or State Identification Number(& State) or Driver’s License Number (& State)

Potential Contradictions:

1. Have you ever received a dose of COVID-19 vaccine?

Yes (Enter product: Pfizer or Moderna)

No

Don't know

2. Are you feeling sick today?

Yes

No

Don't know

3. Have you ever had a severe allergic reaction (e.g., anaphylaxis) in the past? Example: a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital?

Yes

No

Don't know

Was the severe allergic reaction after receiving a COVID-19 vaccine?

Yes

No

Don't know

Was the severe allergic reaction after receiving another vaccine or injectable medication?

Yes

No

Don't know

Was the severe allergic reaction related to receiving Polyethylene Glycol or products containing Polyethylene Glycol?

Yes

No

Don't know

Was the severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?

Yes

No

Don't know

4. Have you received any vaccines in the past 14 days

Yes

No

Don't know

5. Do you have a bleeding disorder or are you taking a blood thinner

Yes

No

Don't know

6. For women, are you currently pregnant or breastfeeding?

Yes

No

Don't know

CONSENT FOR SERVICES: I have been provided with the Vaccine Information 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. I understand that I should remain in 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 I should do the following: call the pharmacy, contact the doctor or 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 One Hanson 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 One Hanson 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 health care operations (such as administration or quality assurance). I also understand that One Hanson Pharmacy will use and disclose my health information as set forth in the One Hanson Pharmacy Notice of Privacy Practices (copy is available in-store, online or by requesting a paper copy from the pharmacy).

AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize One Hanson 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

Vaccine Clinics: If I am receiving a vaccine through a vaccine clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator.

Signature of patient receiving vaccine (or parent, guardian, or authorized representative). The name typed below will represent my signature.

Enter characters for verification.

PRIVACY NOTICE: INFORMATION SUBMITTED FROM THIS FORM IS NOT STORED IN THE WEBSITE DATABASE.

Vaccine Administration Information for Immunizer / Pharmacist use only

Administration Date

Vaccine

VIS Date

Manufacturer

Volume (mL)

Lot #

Exp. Date

Route

Site

If patient's body temperature is 100.4 degrees or greater... Inform them, they should not receive the vaccine at this time.

Administering Immunizer Name & Title

Administering Immunizer Signature

To be filled out by immunizer, as required for state immunization registry reporting.

Check all fields for patients 18 years of age and younger

Check Race and Ethnicity for all patients.

Ethnicity

Hispanic

Not Hispanic or Latino

other

Information provided by:

Submitters Name

Submitters Phone Number

Submitters Relationship

Submitters Address