ONE HANSON PHARMACY
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COVID

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Bridge-Access-Program-General-FAQs.pdf
COVID-19-vis-10.19.2023.pdf
hipaa-notice.pdf
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Location

3286 Old Bridge Road, Woodbridge VA 22192

571-285-1784

Hours of Operation

Monday – Friday: 9am – 7pm

Saturday: Closed

Sunday: Closed

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COVID Vaccine Consent Form

Select X to exit and view the COVID vaccine fact sheet.

Clinic Information:  One Hanson Pharmacy 

3286 Old Bridge Rd, Woodbridge VA 22192

[email protected]

Insurance Information: (For onsite clinics, please ensure a copy of the patient’s insurance card(s)

Medicare Fields:  *Please type n/a if not applicable

Medical Insurance:  *Please type n/a if not applicable

Prescription Insurance:  *Please type n/a if not applicable

If uninsured, you must check the box below to attest that the following information is true and accurate:

In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration’s COVID-19 Program for Uninsured Patients, please provide either (a) a valid Social Security number, (b) state identification number and state of issuance, OR (c) a driver’s license number and the state of issuance.

Potential Contradictions:

CONSENT FOR SERVICES: I have been provided with the Vaccine Information Sheet(s) or patient fact sheet corresponding to the vaccine(s) that I am receiving. I have read the information provided about the vaccine I am to receive. I have had the chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of vaccination and I voluntarily assume full responsibility for any reactions that may result. I understand that I should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should do the following: call the pharmacy, contact the doctor or call 911. I request that the vaccine be given to me or to the person named above for whom I am authorized to make this request.

COVID-19 Program for Uninsured Patients is correct. I authorize the release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.


DISCLOSURE OF RECORDS: I understand that One Hanson Pharmacy® 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 at One Hanson Pharmacy (if applicable), my Primary Care Physician (if I have one), my insurance plan, health systems and hospitals, and/or state or federal registries, for purposes of treatment, payment or other health care operations (such as administration or quality assurance). I also understand that One Hanson Pharmacy will use and disclose my health information as set forth in the One Hanson Pharmacy Notice of Privacy Practices (copy is available in-store, online or by requesting a paper copy from the pharmacy).

AUTHORIZATION TO REQUEST PAYMENT: I do hereby authorize One Hanson Pharmacy® to release information and request payment. I certify that the information given by me in applying for payment under Medicare or Medicaid, or the HRSA is accurate

Vaccine Clinics: If I am receiving a vaccine through a vaccine clinic, I understand that my name, vaccine appointment date and time will be provided to the clinic coordinator.

PRIVACY NOTICE:  INFORMATION SUBMITTED FROM THIS FORM IS NOT STORED IN THE WEBSITE DATABASE.

Vaccine Administration Information for Immunizer / Pharmacist use only

If patient's body temperature is 100.4 degrees or greater...  Inform them, they should not receive the vaccine at this time.

To be filled out by immunizer, as required for state immunization registry reporting.

Check all fields for patients 18 years of age and younger

Check Race and Ethnicity for all patients.

Information provided by:

Vaccination Update / Holiday Hours

UPDATE

  • We are now administering Flu Vaccine. Call to schedule or Walk-in.
  • Ask about our Med Packaging Program. Complex medications with Simple Solution.