UT San Antonio is excited to partner with Passport Health to provide our 2019 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 Blue Cross Blue Shield of Texas PPO • UT Student Insurance administrated by Blue Cross Blue Shield of Texas Other PPO health insurance plan options: • Aetna* • Blue Cross Blue Shield* • 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 $20. Please bring cash or a check made out to Passport Health. UT San Antonio Retirees and dependents covered under the UT Select Plan are eligible to participate. WHAT TO BRING We require that all participants bring both their medical insurance card and driver’s license (or payment if not using insurance) so that the insurance claim can be filed for you. After you register you will receive an email confirmation. You do not need to print the consent form from this email. All information will be collected electronically during the clinic. Depending on insurance carrier, claims may be filed at Passport Health or Staying Healthy Medical Services.
Clinic Location
First Name
Last Name
Email
Confirm Email
Services I'd like to receive
You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.
Medical History Questions
Have you ever had an anaphylactic or severe allergy reaction to any of the vaccines or any component of a vaccine that you are choosing to receive today? Yes No
Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to latex, chicken eggs, egg products, gelatin, neomycin, yeast, or thimerosal, which is found as a preservative in contact lens solution and some vaccines? Yes No
Do you have any history of Guillain-Barre Syndrome? Yes No
Have you ever been dizzy or faint when getting a vaccine or having your blood drawn? Yes No
Are you immunocompromised or taking medications that may cause you to have a decreased immune response to the vaccine? Yes No
Are you pregnant, trying to get pregnant, or breastfeeding? Yes No



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.