Student Tdap Vaccination Consent Form (Page 2 of 2) in pdf

Insurance*: Please answer the following: This information is required for federal funding purposes for VFC vaccines.

*Note: Vaccines will be provided to your child

without charge if the child is eligible for the Vaccines for Children

Program. If your child is covered by health insurance the Department shall seek reimbursement for all allowable costs

associated with the provision of the vaccine.

My child: ( ) is not insured (by private insurance, Medicaid, or FAMIS)

( ) is American Indian or is an Alaska Native

( ) has Medicaid - Medicaid #:

( ) has FAMIS - FAMIS #:

( ) has other insurance not listed above (specify plan) ___________________________

Policy holder’s name______________________

Policy ID # _________________________

Attach a copy of the front & back of insurance card or provide the following information:

Insurance company address __________________________________________________________

Insurance company phone number_____________________________

I authorize VDH to release records necessary to support the application for payment by Medicare, Medicaid,

and other health care benefits. I request the third party payer to pay any authorized benefits to VDH on my

behalf.

Office of Privacy and Security

Authorization for Disclosure of Protected Health Information

This consent gives the Virginia Department of Health (VDH) permission to disclose personal health information to the person(s) or

organization(s) I have indicated.



I understand the provision of treatment to my child cannot be conditioned on my signing of this authorization.



Any health information redisclosed by me or my child will no longer be protected by this authorization.



The original or a copy of the authorization shall be included with my child’s medical record.



I have the right to revoke this authorization at any time, except to the extent that action has been taken prior to my request to

withhold my medical record. The request must be in writing and will be effective upon delivery to the provider in possession

of my medical records.



I authorize VDH to disclose my child’s health information to his/her primary care physician and school.



I understand that this record will be retained for ten years after the last visit or for five years after age 18, whichever comes

later.



I understand this document will be given to and retained by the public health department and will not be maintained by the

school.

 Please check box if you wish to receive a copy of the Virginia Department of Health Privacy Rights.

CONSENT FOR CHILD’S VACCINATION:

I have read the 2013 Vaccination Information Statement (VIS) for the Tdap Vaccine, I understand the risks and benefits, and I give

consent to the Health Department and its authorized staff for my child named at the top of this form to receive the Tdap vaccine (shot).

Signature of Parent or Legal Guardian:

_____________________________________________Date: ____/_____/____

Please send a copy of my child’s immunization record to her/his doctor at the following address.

Doctor’s Name____________________________Mailing Address_____________________________City___________________ State__________ZIP____________

HEALTH DEPARTMENT USE ONLY

Lot Number

Vaccine Administration Site

Date

Item code

Provider #

Comments

Provider Name/Signature and Date

Student Tdap Vaccination Consent Form Page 2

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