Vaccine Clinic Data Collection Form

At this time, there is no direct charge to patients for the COVID-19 vaccination and its administration. The vaccination administration fee will be billed directly to insurance companies.

If you do not have any insurance, including but not limited to Medicare, Medicaid, or any other private or government-funded health benefit plan, the administration fee may be paid for by the United States Health Resources and Services Administration's COVID-19 Program. 

In order to have your vaccine administration fee paid by the United States Health Resources and Services Administration's COVID-19 Program, please provide either of the following:

• Valid Social Security number
• State identification number
• A driver's license number and state of issuance

The following form must be completed prior to your appointment. Be sure to bring the following to your appointment:

• Photo ID
• Medical insurance card