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: contact a 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.
AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize Terros Health 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 COVID-19 Program for Uninsured Patients, is correct. I authorize 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 Terros Health 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 Terros Health (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 Terros Health will use and disclose
my health information as set forth in the Terros Health Notice of Privacy Practices (copy is available online or by requesting a paper copy from the health center).