CONSENT FOR VACCINE:
I have received and read the information about the influenza vaccine and special precautions. I have had an opportunity to ask questions which have been answered to my satisfaction. I am 18 years old or older. I specifically agree that the County of Camden and/or its agents, servants or employees shall not be liable for any injury suffered by me or any other individual as a result of my receipt of the influenza vaccine under any theory of liability, whether in contract, strict liability, or tort and regardless of cause. I reviewed and understand the Camden County Department of Health and Human Services’ Notice of Privacy Practices and have had a chance to ask questions about how my protected health information will be used.
CONSENT TO BILL INSURANCE CCDHHS will not charge any out of pocket fees.
I authorize the submission of a claim to Medicare, Medicaid or any other payer for the services provided to me by CCDHHS now, in the past or in the future, until I revoke this authorization in writing by certified mail. CCDHHS will submit a claim for reimbursement to your insurance provider, any or no payments will be accepted as payment in full. I agree to immediately remit to CCDHHS at the address above any payment that I receive directly from insurance or any source for the services provided to me and I assign all rights to such payments to CCDHHS. I authorize CCDHHS to appeal payment denials or other adverse decisions on my behalf without further authorization. I also authorize CCDHHS to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information. I/We request payment of any medical insurance benefits to go directly to CCDHHS. I/We permit a copy of this authorization to be used in place of the original. A copy of this form is as valid as the original.