1650 Greenfield St., Wilmington, NC 28401
Date of Birth
Select vaccine/vaccines requested
I hereby give consent to New Hanover County Health Department (NHCPH) and its designated personnel for immunizations. Questions will be answered to my satisfaction for this consent to remain valid. I have received and read the appropriate Vaccine Information Statement. I understand that I may access the New Hanover County Health Department Notice of Privacy Practices by visiting http://health.nhcgov.com/ and may call 910-798-3500 to contact the privacy officer to obtain a copy or to address any concerns.
Parent/Guardian Full Name
Date of Signature
I Have Health Insurance
Subscriber Date of Birth
I request payment of authorized 3rd Party Payer (Insurance) and Medicaid benefits made on my behalf to New Hanover County Health Department (NHCHD) for services provided. I authorize any holder of medical information regarding myself to release to the Health Care Financing Administration (HCFA) and its agents any information needed to determine these benefits payable for related services.
I agree to repay the NHCHD any money I receive from insurance for services that the NHCHD provided for me. I further agree that failure to repay assigned insurance benefits to the NHCHD may be reason for denial or restriction of future services until such amounts have been repaid. I understand fees for services submitted to Medicaid, Medicare, or third party insurance which are determined to be non-covered, applied to my deductible or co-insurance are my responsibility. I understand the following services may be non-covered.
I understand that my signature will serve as legal “signature on file” for purposes of filing my Insurance/Medicaid claims and payment of benefits to the NHCHD for services rendered.