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Vaccine Prescreening

General Info

Left/Right Deltoid is the most common choice.

Release of Information / Assignment of Insurance Benefits

I believe I understand the benefits and risks of the influenza and/or pneumonia vaccine and ask that the vaccine be given to me or to the person named above for whom I am authorized to make this request. Under HIP AA provisions, I authorize the release of information about my immunization status and health status for continuing health services only which may include my referring physician or other health care agencies assigned to my care. All health information provided is held in strict confidence, following HIP AA regulations. I acknowledge receipt of Notice of Privacy Practices from Rocky Point Pharmacy. Medicare or 3rd party patients: I do herby authorize Rocky Point Pharmacy to release information and request payment for immunization services. I certify that the information given by me in applying for payment under Medicare or any 3rd party 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. Should any information provided prove incorrect, thus denying payment, I personally guarantee payment for services rendered on my behalf and may be billed accordingly.
Signature is required.

Immunization Screening

It is important to have a personal record of your shots. If you don't have a record card, ask your health care provider to give you one. Bring this record with you to every health care visit. Make sure your health care provider records all of your vaccinations on it.

I agree to be vaccinated today. I have received and understand information about the vaccine or vaccines I will receive. I have had my questions answered to my satisfaction. I authorize the provider performing this service to release to and access from my insurer (if applicable) and primary health care provider any medical or other information necessary. I authorize the payment of medical benefits to the provider performing this service.
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