I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient and confirm that the patient is at least 5 years of age; or (c) legally authorized to consent for vaccination for the patient named above. Further, I hereby give my consent to Inspire Diagnostics or its agents to administer the COVID-19 vaccine.
I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals either 5 years of age or older or 18 years of age and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner.
I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine and have received, read and/or had explained to me the Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction.
I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes (or more in specific cases) after administration for observation. If I experience a severe reaction, I will call 9-1-1 or go to the nearest hospital.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Inspire Diagnostics and its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above.
I acknowledge that: (a) I understand the purposes/benefits of the state’s immunization registry and (b) Inspire Diagnostics will include my personal immunization information in the appropriate state registry and my personal immunization information will be shared with the Centers for Disease Control (CDC) or other federal agencies.
I further authorize Inspire Diagnostics or its agents to submit a claim to my insurance provider or Medicare Part B without supplemental coverage payment for me for the above-requested items and services. I assign and request payment of authorized benefits be made on my behalf to Inspire Diagnostics or its agents with respect to the above-requested items and services. Under the Cares Act, all private, Medicare, and Medi-Caid plans are required to cover COVID-19 vaccines with “no pocket of pocket” costs to their members. (Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered). We accept the reimbursed amount from the insurance company. When the insurance information is incorrect, incomplete, or not provided, Inspire along with all other federal participating providers participates in Insurance Discovery/Communicating information to insurance companies for accurate information which is needed to submit a claim to the insurance company.
Certain plans reimburse the insured member instead of the healthcare provider. This occurs mostly in cases in which the healthcare provider is out of network with that plan. This will generate an invoice from Inspire Diagnostics to collect the reimbursement. If you receive payment from your plan, please deposit the check and send the same amount to Inspire Diagnostics. Please note the name of the person so that we can ensure the payment is applied to the proper claim.
We recommend that the insured member of an out-of-network health plan contact the member services and request that the reimbursement payments are routed directly to Inspire.
CONFIDENTIALITY OF MEDICAL INFORMATION ACT (CMIA), CIVIL CODE § 56, ET SEQ.
Pursuant to California’s Confidentiality of Medical Information Act, I and/or Parent/Guardian authorize Inspire Diagnostics to disclose my COVID-19 vaccination information to the county's Covid Designee/s and Cabrillo College. I and/or Parent/Guardian also authorize the same representatives from the county and Cabrillo College to use the medical information for the purposes described in this authorization.
This authorization is limited to the following types of information and recipients may use the information for the following purpose (s):
This authorization is specifically for the COVID-19 vaccinations administered to prevent Coronavirus Disease 2019 (COVID-19). The recipients will use the information limited to accessing the COVID-19 vaccinations.
Right to Receive Copy of This Authorization: I and/or Parent/Guardian understand that if I consent to this authorization, I and/or Parent/Guardian have the right to receive a copy of this authorization. Upon request, Inspire Diagnostics will provide me with a copy of this authorization.
I and/or Parent/Guardian authorize this vaccination and the disclosure and use of my medical information as described above for the purposes listed above. I and/or Parent/Guardian understand that this authorization is voluntary and by proceeding with the registration, I and Parent/Guardian hereby consent to the terms of this authorization voluntarily.
On behalf of the patient, the patient’s heirs, and personal representatives, I hereby waive any claim I may have against the School District, the County Office of Education, Santa Cruz County Public Health, the healthcare professional, and each of their respective governing board, officers, agents, employees, volunteers, and representatives (“Released Parties”) from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s).