Clinic SignUp Information

UCO Vaccination Clinic
If you have questions regarding the vaccine or your appointment, please contact Passport Health at Accounts@passporthealthusa.com. Appointments are highly preferred and recommended, but not required. We encourage you to register, if you are able, to ensure we are fully prepared for your visit! Please dress with consideration to having your upper arm exposed. We suggest a short sleeve shirt, if possible. After registration - download & bring completed consent form to your appointment. Extra consent forms are available at check-in if you do not have access to a printer. We accept a limited number of insurance plans - Aetna, Blue Cross Blue Shield, Cigna, Community Care, Global Health, HealthCare Highways, HealthChoice, HealthSmart, Humana (Medicare Advantage Only), Soonercare/Medicaid, Medicare (Part B), UMR, United Healthcare (not if card says "referrals required"), United Healthcare Medicare Advantage. If you have one of the following insurance providers, please bring your health insurance card or a clear copy of both sides of the card. If you do not have health insurance or if you have insurance through a plan that is not listed above, you can still participate. UCO will cover the cost of the Flu vaccine for UCO students and staff without insurance or for those covered under a plan we do not accept. Please note, there are a limited number of "UCO Pay" Flu vaccines. DO NOT ATTEND THIS EVENT IF ARE FEELING SICK INCLUDING FEVER, COLD OR FLU LIKE SYMPTOMS, OR TESTED POSITIVE FOR COVID IN THE PREVIOUS 14 DAYS
Clinic Location
Date
Time
First Name
Last Name
Date of Birth
Email
Confirm Email
Mobile Phone Number
Gender
Address
City
State
Zip
Insurance Billing Information
Insurance Provider
Provider Name
Medicare ID
Member ID
Group ID
Insured through	Self Spouse / Domestic Partner Parent Other

Name
Address
DOB

Services I'd like to receive	COVID, 2025-2026 Pfizer (12+ years) Flu High Dose Flu Shot (for ages 65+)

You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.

Need help? Contact us at Accounts@passporthealthusa.com

Passport Health is committed to keeping your personal data safe and we endeavor to take every reasonable precaution to ensure security. Passport Health complies with health care data reporting requirements of State and Federal authorities, as well as subpoenas, and may use or disclose data as required or requested for billing and payment purposes. Outside of this, access to your personal information is restricted to employees at Passport Health for internal purposes only and is never sold.

I consent to receiving immunizations from Passport Health. I have been given an opportunity to review the Vaccine Information Statements located here. At the time of my appointment I will be made aware of certain risks that may be associated with the vaccine(s) including the potential for allergic reaction and I will be offered the opportunity to ask questions and I believe that the benefits outweigh the risks. I assume full responsibility for any reactions that may result. I authorize Passport Health to disclose my health information to my state immunization registry, my physician, my employer and my insurance company. I authorize Passport Health to notify me of future health events, services or products. I hereby acknowledge receipt of Passport Health's Notice of Privacy Practices. If I am signing this consent on behalf of another individual, I hereby certify that I have the legal right to do so as the person's parent or legal guardian, pursuant to a health care power of attorney, pursuant to a court order, or pursuant to some other legal right to consent to health care for the individual. I agree that the insurer or payer listed above is my primary medical coverage and that I am responsible for payment if services are not covered for any reason or are subject to any co-pays, deductibles, coinsurance or prior authorizations.