Flu Immunization Consent Form
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2FLU IMMUNIZATION CONSENT
Please Print:
Age 9 years and older
__________________________________
__________________________________
____________
Last Name
First Name
Middle Initial
___________________________________ _____________________________ _____
___________
Address
City
State
Zip
________-________-________
_______
_______________________
Date of Birth
Age
Phone Number
Sex (circle): Male Female
______________________________________
Email Address
ALL MEDICARE PERSONS – PLEASE COMPLETE THIS SECTION
Person has Traditional Medicare Part B as the PRIMARY insurance
Medicare Number
(Please keep your card out for verification)
MEDICARE HMO PERSONS – COMPLETE THIS SECTION IN ADDITION TO SECTION ABOVE
Person DOES NOT have Medicare Part B as the PRIMARY insurance but has a Medicare Advantage plan
(complete below and please use the card that you give to your physician or for hospital visits – your drug plan
or your supplemental coverage plan does not pay for the flu immunization):
Medicare HMO
__________________________________
Member ID Number _________________________________ (Please keep your card out for verification)
I understand Borgess will bill my Medicare Plan, however, I accept full responsibility for any charges not
covered by my Medicare Plan.
BORGESS STAFF – Please fill out this section (cardholder must sign below for credit card payments)
Cash
Visa
Payment:
Check
Master Card
□
□
Insurance
Discover
Credit Card Information:
Name on Card____________________________Signature______________________________
Address: _______________________________City_____________State_________Zip_____
16 digit credit card number____________________________________ Exp. Date____________
3 digit code from back of card __________________
Billing/payment information verified by: ____________________
CONTINUED ON OTHER SIDE
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