Common Contracts

COVID-19

November 17th, 2021

• Filed
  November 17th, 2021

Last Name (please print) First Name Middle Initial Birth Date (mo/day/year) Age Street Address Email Phone Male Female🖵 🖵 City State Zip Code Mother’s Name (last, first, middle - if younger than 18 years): Information collected on this form will be used to document that you have received vaccine(s). Immunization information may be shared through the Minnesota Immunization Information Connection (MIIC) with other health care providers, schools, health departments, and others authorized under law to receive it. If you have any questions, please ask your health care provider. If you have questions about MIIC, refer to MIIC and the Public (www.health.state.mn.us/people/immunize/miic/public.html) or call 1-800-657-3970.Assignment of benefits and responsibilities for payment: This allows us to bill your health plan or company and receive payment directly. There is no cost for the COVID-19 vaccine, although you may be billed an administration fee.I authorize this health provider to bill my he