Clinic SignUp Information

Yukon Public Schools Student Vaccine Clinic
Please sign up for an appointment time using parent/guardian contact information. Please complete one consent form for your student and bring it with you on clinic day. Please also bring a copy of your insurance card and/or your actual insurance card. We currently accept the following insurance providers: Aetna • Advantage/ Healthsmart • All Savers • Assurant Health • BlueCross BlueShield • Bluelincs • CHAMPVA (25% co-insurance applies that will be billed to patient after insurance payment is received) • Christian Healthcare Ministries • Cigna • CoreSource • Coventry • First Health • Freedom Life • GEHA • GlobalHealth • Healthcare Highways • HealthChoice • Healthscope • Healthsmart • Humana • Kempton Group • Meritain • Mail Handlers Benefit • Multiplan • Mutual Assurance • Resource One • Samaritan Ministries • Solidarity Healthshare • SoonerCare (18 years & younger) • Tricare Standard/Tricare East (NOT Tricare PRIME) • UMR • United HealthCare (Not if card says, “Referrals Required”) • WEBTPA (Integris plan NOT included) If your student is not covered under any insurance plan, they are still invited to participate via the Vaccines for Children Program at no cost. If you need assistance or have questions regarding immunizations, please contact Passport Health at 405-563-8961 For school enrollment, a parent or guardian shall provide one of the following: 1. Current, up-to-date immunization records; or 2. A completed and signed exemption form, please contact your school directly for information regarding exemption forms.
Clinic Location
Date
Time
First Name
Last Name
Date of Birth
Email
Confirm Email
Mobile Phone Number
Please select the option that best describes your child's insurance coverage.
Services I'd like to receive	HPV Meningitis Tetanus, Diphtheria, Pertussis (TDaP) 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 myclinic@passporthealthok.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.