Book with Vaccine Van Rx

Consent to Vaccinate. I voluntarily request and consent that Jeff Robert Godin, PharmD (Florida pharmacist license PS 49125), or another Florida-licensed pharmacist, administer the vaccine(s) I selected to me, or to the patient for whom I am legally authorized to consent. The vaccines given at this visit are administered under the standing order protocol of My Concierge Pharmacy, PLLC and its supervising physician, Cedric Davis, MD, and are dispensed by My Concierge Pharmacy, PLLC, the dispensing pharmacy of record. The pharmacist has explained the nature and purpose of the procedure, its material benefits and risks (including local reaction, systemic reaction, fainting, and very rarely a severe allergic reaction), and reasonable alternatives, including declining vaccination. I confirm that I received, or was offered, the current CDC Vaccine Information Statement or EUA Fact Sheet for each vaccine selected, that I had a meaningful opportunity to read it and ask questions, that my questions were answered, and that I understand the benefits and possible adverse reactions of vaccination. This consent is given pursuant to and is intended to satisfy §766.103, Fla. Stat.

Truthfulness of Screening. I certify that the information on this form is true and complete to the best of my knowledge, and that inaccurate or omitted information may increase the risk of an adverse reaction and may affect the validity of this consent.

Insurance and Assignment of Benefits. If I provided insurance information, I authorize My Concierge Pharmacy, PLLC to submit claims to my insurer, and I assign to My Concierge Pharmacy, PLLC the right to receive payment directly. I authorize Vaccine Van Rx, LLC to transmit my insurance and health information to My Concierge Pharmacy, PLLC for that purpose. I understand that different vaccines bill to different parts of Medicare, that I may be responsible for deductibles, copays, coinsurance, or non-covered services, and that an ABN (CMS-R-131) will be provided where Medicare denial is expected.

Privacy, Records, and Reporting. Vaccine Van Rx, LLC is a mobile immunization service brand and is not the pharmacy. My Concierge Pharmacy, PLLC is the dispensing pharmacy of record and holds the pharmacy record of my vaccination. I authorize Vaccine Van Rx, LLC to share my health information with My Concierge Pharmacy, PLLC for treatment, payment, and health care operations. I acknowledge that I received, or was offered, the Notice of Privacy Practices of My Concierge Pharmacy, PLLC, which governs that information under HIPAA, and the Vaccine Van Rx Privacy Policy, posted at vaccinevanrx.com, which governs the information Vaccine Van Rx holds. I consent to the reporting of my immunization to Florida SHOTS, the state immunization registry, under My Concierge Pharmacy's registry account. I understand that adverse events are reported to the federal Vaccine Adverse Event Reporting System (VAERS) as required by law. I consent to vaccination reminders and second-dose follow-up by phone, text, or email. Questions about this visit or your bill? Call (561) 247-1577.