COVID-19 Vaccine Patient Registration and Consent - FPCC

Please complete the following information and submit.

COVID-19 Vaccine: *

COVID-19 Vaccine: Moderna Pfizer J&J
COVID-19 Vaccine - Moderna Dosage *

COVID-19 Vaccine - Moderna Dosage Moderna 1st Dose Moderna 2nd Dose Moderna - Booster
COVID-19 Vaccine - Pfizer Dosage *

COVID-19 Vaccine - Pfizer Dosage Pfizer 1st Dose Pfizer 2nd Dose Pfizer - Booster
Demographics
Name Name * First Last
Birth Date Birth Date * / MM / DD YYYY
Address Address *
Street Address
Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone * - ### - ### ####
Cell Phone Cell Phone * - ### - ### ####
Email *
Marital Status *

Marital Status Single Married Domestic Partner Divorced Widowed
Student Status: *

Student Status: Full-Time Part-Time N/A
Education Level: *

Education Level: PreK-12 High School/GED Technical Training Some College Associates Bachelors Masters PhD
Emergency Contact Name *
Emergency Contact Phone Number Emergency Contact Phone Number * - ### - ### ####
Birth Sex: *

Birth Sex: Male Female
Current Gender: *

Current Gender: Male Female Other
Gender Identity: *

Gender Identity: Male Female Transgender Female-to-Male Transgender Male-to-Female Other Choose not to disclose
Sexual Orientation: *

Sexual Orientation: Decline to Disclose Straight Gay or Lesbian Bisexual Other Unknown
Race: *

Race: Native American/Native Alaskan Black/African American Asian Caucasian Native Hawaiian/Pacific Islander Latino Refuse to Report
Ethnicity:

Ethnicity: Hispanic Non Hispanic
Primary Care Provider Information
Name of Primary Care Provider (PCP):
Address of Primary Care Provider (PCP): Address of Primary Care Provider (PCP):
Street Address
Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone number of Primary Care Provider (PCP): Phone number of Primary Care Provider (PCP): - ### - ### ####
Fax number of Primary Care Provider (PCP): Fax number of Primary Care Provider (PCP): - ### - ### ####
Consent for COVID-19 Vaccination
I will/have reviewed my answers of the Pre-Vaccination Checklist for COVID-19 Vaccines to the vaccinator. I understand that I am voluntarily receiving the COVID-19 vaccine. If I experience any adverse reactions after leaving, I will notify my primary care provider. I have reviewed the Emergency Use Authorization Fact Sheet provided to me today. I understand the benefits and risks of the vaccine.
The COVID-19 vaccine being given today should be given to the named above for whom I am authorized to make this request. I understand that I can review a Notice of Privacy Practice at the time of vaccination.
Signature of patient/guardian *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date
(Auto Filled) Date
(Auto Filled) / MM / DD YYYY
Insurance Information
Type of Insurance
(Select all that apply):

Type of Insurance
(Select all that apply): Private/Commercial Medicare Medicaid Uninsured Lien Workman’s Compensation
Please select your Nevada Medicaid plan (if applicable):

Please select your Nevada Medicaid plan (if applicable): Anthem Medicaid HPN Smart Choice Medicaid Silver Summit Medicaid Fee-For-Service
Primary Insurance
Policy Number
(Primary Insurance)
Group Number
(Primary Insurance)
Name of Policy Holder
(Primary Insurance) Name of Policy Holder
(Primary Insurance) First Last
DOB
(Primary Insurance) DOB
(Primary Insurance) / MM / DD YYYY
Policy Holder:
(Primary Insurance)

Policy Holder:
(Primary Insurance) Self Parent Spouse/Domestic Partner
Secondary Insurance
Policy Number
(Secondary Insurance)
Group Number
(Secondary Insurance)
Name of Policy Holder
(Secondary Insurance) Name of Policy Holder
(Secondary Insurance) First Last
DOB
(Secondary Insurance) DOB
(Secondary Insurance) / MM / DD YYYY
Policy Holder:
(Secondary Insurance)

Policy Holder:
(Secondary Insurance) Self Parent Spouse/Domestic Partner
Notice of Privacy Practices Acknowledgement

As a requirement of the Health Insurance Portability and Accountability Act (HIPAA); First Person Care Clinic is committed to protecting your Personal Health Information (PHI) and the following is a brief description of how your care team manages your personal health information per Federal and Nevada State Laws.
The following information is protected under our privacy practice policy:
1) Personal Information that can be used to identify you including, but not limited to your name, date of birth, social security number, address, and phone number.
2) Medical information that includes, but not limited to your current medical condition.
3) Conversations between you and the First Person Care Clinic medical or dental providers and staff.
The following personnel will have access to your medical information:
1) Providers (Physicians, Dentists, Nurse Practitioners, Physician Assistants, Pharmacists, Therapists) who are employed or contracted with First Person Care Clinic that are authorized to access or enter information into your file or chart.
2) Medical Support Staff (Registered Nurses, Licensed Practical Nurses, Medical Assistants, Medical Administrative Assistants, Referral Specialists, Patient Representatives) whom are employed or contracted with First Person Care Clinic
that are authorized to access or enter information into your file or chart.
3) Students and/or volunteers from schools or organizations that are contracted to practice at First Person Care Clinic and its
facilities.
4) Hospitals and first responders that are needed for immediate emergency care.

Coordinating your medical information
- First Person Care Clinic may submit your medical information to your health insurance and/or to their contracted third- party organization as requested by your health insurance to comply with Healthcare Effectiveness Data and Information
Set (HEDIS) measures.
- Limited medical information may be shared with other physicians, pharmacists, and/or durable medical equipment
companies as a referral to coordinate your care plan.
- First Person Care Clinic is a collaborating organization with the Nevada Health Information Exchange (HIE) and the Nevada WebIZ, which allows the Nevada HIE and Nevada WebIZ to obtain your medical information or vaccination
information directly from our Electronic Medical Records (EMR); this may be declined at any time by completing the Nevada HIE consent form or in writing the Nevada WebIZ. Nevada Medicaid recipients may NOT opt out of the Nevada
Health Information Exchange as part of the Nevada Medicaid policy.
- First Person Care Clinic may also contact you by means of phone calls, e-mails, patient portal messages, and/or text
messages to remind you of scheduled appointments, in which no medical information will be discussed or mentioned.
YOUR RIGHTS:
Your right as a patient may request, in writing, restrictions on the use or sharing of any information, received confidential
communication, inspect and receive copies of shared information, received an accounting of shared information and amend or revoke authorization; except in medical emergencies and in any case we suspect or are aware of harm to yourself and/or others.
A copy of our complete Privacy Practice Policy may be provided upon request. An alternative means of obtaining a copy of our Privacy Practice Policy may found on our website at https://firstpersonclinic.org.
By signing below, you agree with out Privacy Practices as required by HIPAA.
Print Name of Patient/Parent/Legal Guardian/POA *
Signature of Patient/Parent/Legal Guardian/POA *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Patient Name Patient Name * First Last
Patient DOB Patient DOB * / MM / DD YYYY

COVID-19 Vaccine Patient Registration and Consent - FPCC

COVID-19 Vaccine Patient Registration and Consent - FPCC

Demographics

Primary Care Provider Information

Consent for COVID-19 Vaccination

Insurance Information

Notice of Privacy Practices Acknowledgement