Phone number: 877-MEDS 247 or 717-893-7746 , Email: Info@medspack.com
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.
I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) 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 the 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 that if I experience side effects that I should: call pharmacy, contact doctor, 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 Medspack 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 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 Medspack Pharmacy may be required to or may voluntarily disclose my health information to the physician responsible for this protocol or specific health information of people vaccinated at Medspack, 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 Medspack Pharmacy will use and disclose my health information as set forth in the Medspack Pharmacy Notice of Privacy Practices (copy available by request or online).
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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