Consent and Authorization
I. Consent for Vaccine and Treatment (if applicable)
By selecting “Accept” below, I agree that e3Health Solutions, LLC, doing business as eTrueNorth (“eTrueNorth”), may coordinate administration of a vaccination, or booster dose of a prior vaccination (as applicable, the “Vaccine“), intended to prevent the novel coronavirus disease (“COVID-19“) for the individual who is registered (the “Vaccine Recipient“).
In addition, I understand, certify, and agree that:
- I am the Vaccine Recipient and I am at least eighteen (18) years of age; or I am the guardian or legal representative of the Vaccine Recipient, I am authorized to act on behalf of the Vaccine Recipient regarding the Vaccine, and I represent that the Vaccine Recipient is at least eighteen (18) years of age.
- eTrueNorth is coordinating administration of the Vaccine among various parties with whom it contracts, including pharmacies, health plans, pharmacy benefit plans, and other third-party claims processors (“Contractors”), as part of the Center for Disease Control and Prevention’s (“CDC”) Bridge Access for COVID-19 Vaccine Program (the “Bridge Access Program”).
- The personal, health, and/or insurance information I am providing to eTrueNorth and any of its Contractors regarding my eligibility for the Vaccine is accurate, and I request that the Vaccine be given to me.
- The Vaccine Recipient’s eligibility to receive the Vaccine will depend on objective, scientifically determined eligibility criteria established by the CDC and verified by Contractors prior to administration of the Vaccine.
- The Vaccine will be stored, prepared, and administered by a Contractor, not by eTrueNorth.
- I have read the Patient Fact Sheets and/or Vaccine Information Statements provided to me by eTrueNorth or its Contractors regarding the Vaccine. I understand the benefits and risks of the Vaccine and voluntarily assume full responsibility for any reactions or consequences that may result from the Vaccine I have elected to receive.
- I will adhere to the protocols and instructions of the Contractor administering the Vaccine to me, such as remaining in the vaccine administration area for 15 minutes, or longer if directed, after I receive the Vaccine to be monitored for potential adverse reactions.
- In the event of side effects, I understand that I should call the Contractor who administered the Vaccine, my doctor, or 911.
II. HIPAA Authorization
I hereby consent to and authorize the use and disclosure of the Vaccine Recipient’s protected health information, as applicable: (i) with any Contractors, pharmacy, healthcare facility, and/or any physician for the purposes of providing the Vaccine Recipient with medical treatment in connection with any adverse reaction to the Vaccine; (ii) with any federal or state governmental agency or entity for purposes of payment to cover the cost of the Vaccine or for any other purpose required by such federal or state governmental agency, including mandatory state registry or health information exchange reporting; and (ii) in any manner permitted by federal or state privacy and security laws. This consent and authorization is valid as of the day this document is signed by me and expires after one (1) year.
In addition, I understand and acknowledge the following:
- I understand that I have the right to revoke this consent and authorization (except for the provisions set forth in Article III) at any time that I so choose by notifying eTrueNorth. If I revoke this consent and authorization, I understand that the revocation would only apply after I notify eTrueNorth.
- I understand that my consent and authorization will result in the use or disclosure of the Vaccine Recipient’s protected health information. Though precautions will be taken to protect the confidentiality of this protected health information, I understand that the transmission of protected health information presents risks and that the confidentiality of such information may be compromised by failures of security safeguards or illegal tampering.
- I understand that there are purposes/benefits of my state’s vaccination registry (“State Registry”) and my state’s health information exchange (“State HIE”); and that the eTrueNorth and/or its Contractors may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, or to any state or federal governmental agencies or authorities (“Government Agencies”), such as state, county, or local Departments of Health or the federal Department of Health and Human Services, the CDC, or their respective designees as may be required by law, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination.
- Depending on my state’s law, I may need to specifically consent, and, to the extent required by my state’s law, by signing below, I hereby do consent to eTrueNorth reporting my vaccination information to the Government Agencies, State HIE, or through the State HIE and/or State Registry to the entities and for the purposes described in this Consent and Authorization document.
- The Contractor administering the Vaccine to you will provide you additional information regarding reporting to a State Registry and/or State HIE and your ability to “opt-out” of such reporting, if applicable. If you opt-out, you will need to provide a copy of any Opt-Out Form to eTrueNorth.
- Unless I provide eTrueNorth with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to eTrueNorth and/or my State HIE, as applicable. I understand that even if I do not consent or if I withdraw my consent, my state’s laws or federal law may permit certain disclosures of my vaccination information to or through the State HIE or to Government Agencies as required or permitted by law.
- I understand that I may receive a copy of this Consent and Authorization by accessing “www.covidaccess.com” or by calling (800) 635-8611.
III. Billing Authorization
I understand that I am receiving the Vaccine as part of the Bridge Access Program, and that the cost of the Vaccine will be billed to my health insurance or pharmacy benefits plan (collectively, “Insurance”). If I do not have such Insurance, the cost of the Vaccine will be covered by the Bridge Access Program.
In the event my Insurance does not cover the full cost of my Vaccine and the pharmacy I choose to administer my Vaccine is not in-network with my Insurance, I understand that I may be responsible for any amounts not covered, but such amount will not exceed $200 and I voluntarily agree to the following:
- I hereby authorize and direct my Insurance provider to issue payment to eTrueNorth or its Contractor for any Vaccine that the Vaccine Recipient receives. To the extent applicable, I agree to promptly pay on demand any and all obligations.
- I acknowledge that, if I voluntarily requested a Vaccine from eTrueNorth on behalf of the Vaccine Recipient, but I (a) provided incorrect information regarding my Insurance; and/or (b) use a pharmacy that is not in-network with my Insurance, I may be fully financially responsible for any charges associated with such Vaccine.
- I authorize eTrueNorth to (i) release any information necessary to my Insurance, state registry, or the Centers for Disease Control and Prevention regarding my Vaccine and health status; and (ii) process insurance claims generated in connection with my receipt of the Vaccine.
In consideration for receiving the opportunity to obtain the Vaccine, I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE eTrueNorth and its respective officers, servants, agents, employees, direct or indirect owners, or direct or indirect subsidiaries (the “eTrueNorth Releasees”) from and against any and all SUITS, ACTIONS, LOSSES, DAMAGES, CLAIMS, OR LIABILITY OF ANY CHARACTER, TYPE OR DESCRIPTION, INCLUDING ALL EXPENSES OF LITIGATION, COURT COSTS, AND ATTORNEY’S FEES FOR INJURY OR DEATH TO ANY PERSON, OR INJURY TO ANY PROPERTY, RECEIVED OR SUSTAINED BY ANY PERSON OR PERSONS OR PROPERTY, ARISING OUT OF, OR OCCASIONED BY, DIRECTLY OR INDIRECTLY, WHETHER CAUSED BY THE NEGLIGENCE OF THE ETRUENORTH RELEASEES OR OTHERWISE, OR THE VACCINE RECIPIENT’S PRESENCE ON A PHARMACY’S PROPERTY TO OBTAIN THE VACCINE. I hereby accept and assume all risks involved in receiving the Vaccine (through administration by Contractors) and fully assume all responsibility for injury, damage, or claim of any nature whatsoever that may result from receiving such Vaccine.
In addition, I also hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE eTrueNorth’s Contractors, including the pharmacy administering my Vaccine, and their officers, servants, agents, employees, direct or indirect owners, or direct or indirect subsidiaries (the “Contractor Releasees”) from and against any and all SUITS, ACTIONS, LOSSES, DAMAGES, CLAIMS, OR LIABILITY OF ANY CHARACTER, TYPE OR DESCRIPTION, INCLUDING ALL EXPENSES OF LITIGATION, COURT COSTS, AND ATTORNEY’S FEES FOR INJURY OR DEATH TO ANY PERSON, OR INJURY TO ANY PROPERTY, RECEIVED OR SUSTAINED BY ANY PERSON OR PERSONS OR PROPERTY, ARISING OUT OF, OR OCCASIONED BY, DIRECTLY OR INDIRECTLY, WHETHER CAUSED BY THE NEGLIGENCE OF THE CONTRACTOR RELEASEES OR THE VACCINE RECIPIENT’S PRESENCE ON A PHARMACY’S PROPERTY TO OBTAIN THE VACCINE. I hereby accept and assume all risks involved in receiving the Vaccine (through administration by Contractors) and fully assume all responsibility for injury, damage, or claim of any nature whatsoever that may result from receiving such Vaccine.
In addition, by selecting “Accept” below, I certify that (i) this document has been completely explained to me; (ii) I read this document or someone read it to me; (iii) all of my questions regarding this document have been answered; (iv) I completely understand this document; and (v) I agree with all statements made in this document.