Clinic SignUp Information

UT Arlington Flu Clinic
UT Arlington is excited to partner with Passport Health/Staying Healthy Medical Services to provide our 2022 onsite Flu Shot Clinics. Please complete this online registration form and follow the below instructions so you are prepared for your appointment. For employees with the following insurance, your immunizations are covered at 100% under your plan. • UT SELECT & CONNECT Blue Cross Blue Shield of Texas PPO Other health insurance plan options: • Blue Cross Blue Shield* • Aetna* • Cigna** • Humana • United Health Care • Medicare Part B (please provide copies of any supplement plans also) We are unable to accept Aetna & Blue Cross Gold, Silver or Bronze plans. *We are unable to accept Cigna Local Plus plans. We are unable to accept HMO plans. If you do not have one of the accepted insurance plans you can still get a flu shot for $29. Please bring cash or a check made out to Staying Healthy Medical Services. The Moderna COVID-19 vaccine will be available for participants age 18 and up for primary doses (dose 1 or 2). The new Moderna Bivalent formula of the vaccine will also be available for age 18 and up for booster doses. If previous doses were with Pfizer vaccine, Moderna can be received for a booster dose. There must be at least 2 months between previous doses and the new booster vaccine. WHAT TO BRING We require that all participants bring a PHOTO COPY of both their medical insurance card and driver’s license so that the information is correctly submitted for insurance coverage. The driver’s license number can be marked out. In addition, after you register, you will see a confirmation message containing a link to a consent form. Please click the link to download the consent form and bring a signed copy with you to your appointment. This will ensure the shortest possible wait. Depending on carrier, insurance claims may be filed as Staying Healthy Medical Services or Community Health and Immunizations. Thank you!
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Services I'd like to receive	COVID-19 Vaccine Flu Shot Injection

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 info@stayinghealthymedical.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.