All information obtained will be used for the express purposes of providing immunization services and cannot be used by any other federal, state or local agencies for any other activities.
Please bring your insurance card to your immunization appointment
General Consent & Financial Agreement: I consent to the rendering of an examination and treatment by Morgan County Health Department employees and their contractors. I accept the risks involved with the nature and purposes for all procedures associated with my care and treatment and understand, I have the opportunity to ask questions and have them answered to my satisfaction. I understand that any and all services are rendered on a voluntary basis; I also have the right to refuse or stop services at any time. I understand that electronic medical records are maintained and secured utilizing Custom Data Processing (CDP). The system collects client data and visit information and calculates billing on behalf of the Morgan County Health Department. I authorize the Morgan County Health Department to release information from my medical record to any health care provider participating in any way in the care of the patient and to any person or entity which is or may be liable for all or part of the charges for services received. I understand that following release of medical records or information, the Morgan County Health Department will no longer be responsible for the confidentiality of any documents released in accordance with this authorization If I am eligible for any Commercial Insurance and/or Medicaid coverage, I agree to notify the Morgan County Health Department of the nature and extent of my coverage at the time of signing this document. I hereby authorize payment of benefits by any third party payer directly to the Morgan County Health Department for services rendered. By signing below, I acknowledge that I was offered a copy of the Morgan County Health Department Notice of Privacy Practices, HIPAA. I understand that I should read it carefully. In consideration of the services provided, the undersigned agrees to pay all charges of the Morgan County Health Department if applicable. Each bill is due and payable upon presentation (at time of service) or mailing of same to either the patient and/or the guarantor, unless other payment arrangements are made. I CERTIFY THAT I UNDERSTAND AND AGREE TO THE PROVISIONS CONTAINED WITHIN THIS AGREEMENT. I voluntarily give permission for treatment by the Morgan County Health Department.