Authorization | Information GRITS DATA COLLECTION FORM - PatientSCREENING QUESTIONS1. Are you sick today? Yes No Unknown2. Do you have any allergies to any contents in this vaccine, which include polyethylene Glycol (PEG) OR to polysorbate Yes No Unknown3. Do you ever had any allergic reaction (severe or Immediate) to any vaccines inducing mRNA Yes No Unknown4. Do you have a bleeding disorder or are you on a blood thinner? Yes No Unknown5. Are you immunocompromised or on any medication that affects your immune system? Yes No Unknown6. Have you received a COVID-19 vaccine previously? Yes No UnknownIf Yes, Date 7. Femalea) Are you or could you be pregnant? Yes No Unknownb) Are you planning to become pregnant? Yes No Unknownc) Are you breastfeeding? Yes No Unknown8. In the past two weeks, have you tested positive for COViD-19 or have you currently been Exposed to someone with COVID-19? (for healthcare personnel have you had a high-risk exposure for which you have been recommended to quarantine?) Yes No Unknown9. If you were with COVID-19 in the past 90 days did you receive antibody therapy or convalescent plasma for treatment of COVID illness? Yes No Unknown10. Have you had any vaccinations in the past 14 Days? Yes No UnknownACKNOWLEDGEMENT I was provided the Fact Sheet for Recipients for the COVID-19 vaccine I am receiving. I read and/or had explained to me the information provided about the vaccine. I was given the chance to ask questions and any questions I had were answered to my satisfaction. I understand the risks and benefits of the vaccination and I am voluntarily choosing to get the vaccination. I understand I should remain in the vaccine administration area 15 minutes after the vaccination to be monitored for any potential adverse reactions. If I have had a previous severe reaction to a vaccine. I will be monitored for 30 minutes. I understand if I experience any side effects aner leave them or if the side effects are severe. I should call 911. AUTHORIZATION FOR PAYMENT I authorize the release of my personal, billing, and medical information to third-party payers, insurance companies review agencies. for use in connection with payment, including eligibility for payment, regulatory accreditation compliance, or as is required for a provider to receive payment or reimbursement for care. I authorize and irrevocably assign to the administrator of the vaccine payment of any benefits payable to Mel amounts payable for the vaccine I receive. DISCLOSURE OF RECORDS I understand U-First Healthcare may be required to or may voluntarily disclose my health information to the physician responsible for this protocol of specific health information of people vaccinated by U-First Healthcare, my Primary Care Physician, (If have one), my insurance plan, health systems, and hospitals, and/or state/federal registers for purposes of treatment, my payment or other health care operations. I also understand that U-First Healthcare will use and disclose my health information as set forth in the Ministry Notice of Privacy practices (a copy is available upon request). I agree that U-First Healthcare and its business associates may contact me by any phone number provided by me or associated with my health including my cell phone, which could result in charges to me. U-First Healthcare also may contact me via text messages or emails, using the information provided. Methods of contact may include using prerecorded/artificial voice messages and/or the use an automatic dialing device. Birth DatePatient Name:DateDateConsent & Acknowledgment PATIENTS WHO ARE 5 to 17 YEARS OF AGE I consent for U-First Healthcare to provide the COVID-19 vaccine to the patient identified below. I acknowledge that I read this document as well as the Fact Sheet. Vaccine Recipient.DateGRITS DATA ENTRY FOR INTEGRATION WITH OFFICE ALLYPatient Last Name:Patient First Name:Patient DOB:Patient EthnicityAddressCityStateZip Code
