Flu Shot Form - Grange » LifeCare Alliance

Hidden

LOCATION

First Name(Required)

Last Name(Required)

Middle Initial

Age(Required)

Email(Required)

Phone(Required)

Name of PRIMARY Health Insurance Company(Required)

Member ID of PRIMARY Health Insurance Holder(Required)

Insured's Name(Required)

Relationship with Insured(Required)

List Any Secondary Insurance

Other - Describe

2nd application

First Name(Required)

Last Name(Required)

Middle Initial

Age(Required)

Email(Required)

Phone(Required)

Name of PRIMARY Health Insurance Company

Name of PRIMARY Health Insurance Holder

Other - Describe

3rd application

First Name(Required)

Last Name(Required)

Middle Initial

Age(Required)

Email(Required)

Phone(Required)

Name of PRIMARY Health Insurance Co.

Name of PRIMARY Health Insurance Holder

Other - Describe

4th application

First Name(Required)

Last Name(Required)

Middle Initial

Age(Required)

Email(Required)

Phone(Required)

Name of PRIMARY Health Insurance Co.

Name of PRIMARY Health Insurance Holder

Other - Describe

Hidden

Vaccination Consent

I am providing consent for LifeCare Alliance to vaccinate me as indicated below, or the person named above for whom I am authorized to make this request. I have read and understand the information I have received about the vaccine(s), possible side effects and contraindications.  I have had a chance to ask questions.  I believe the benefits outweigh the risk of vaccination(s) and ask that the vaccine be given.  I voluntarily assume full responsibility for any reaction for any reactions that may result from either my receipt of the immunization(s) or receipt of the immunization below by the person for whom I am legal guardian.  To the extent permitted by law, I agree to indemnify and hold harmless LifeCare Alliance and any employees, representatives, officers, and agents (LifeCare Alliance indemnified parties) from and against all loss, cost, damage, or expense, including reasonable attorney fees arising from claims against any LifeCare Alliance indemnified parties by reason of injury to or death of any person suffered or claimed to have been suffered, by me in whole or part, by any act or omission of LifeCare Alliance or any of its employees, representatives, or agents.  I accept responsibility for seeking medical attention for any problems associated with receiving the vaccination (s) .  I authorize LifeCare Alliance to release medical/demographic information necessary to file a claim. I understand that LifeCare Alliance will accept assignment of my claim and I authorize my insurance company to pay benefits directly to LifeCare Alliance.  If my insurance coverage is not in effect or if this service is not covered I am financially responsible for the balance due.  Health records are protected under federal/state confidentiality laws and this consent form is valid for the release of information for treatment, payment and oversight functions only.  The LifeCare Alliance Notice of Use of Private Health Information brochure has been made available to me.

Hidden

Signature

Hidden

STAFF USE BLOCK

Hidden

STAFF USE BLOCK

Hidden

STAFF USE BLOCK

Hidden

STAFF USE BLOCK

Hidden

STAFF USE BLOCK

This is a sign-up form for Flu Shot appointments at Grange Insurance in the Old Credit Union Space (On first floor)
either on October 3rd, or October 24th.

2nd application

3rd application

4th application

Connect

Donate

Volunteer

About

Programs

Locations

This is a sign-up form for Flu Shot appointments at Grange Insurance in the Old Credit Union Space (On first floor) either on October 3rd, or October 24th.

2nd application

3rd application

4th application

Connect

Donate

Volunteer

About

Programs

Locations

This is a sign-up form for Flu Shot appointments at Grange Insurance in the Old Credit Union Space (On first floor)
either on October 3rd, or October 24th.