Clinic SignUp Information

Tulane Student Flu Shot Clinic Sign Up

I acknowledge that, in order to facilitate the billing of insurers, Tulane University Campus Health (TUCH) may need to share certain, limited portions of my Treatment Records, including the data collected by Passport Health, with third parties. Because the act of sharing this information may eliminate certain protections, TUCH will voluntary apply federal HIPAA regulations for the privacy of Protected Health Information to such shared Treatment Records. I further acknowledge that TUCH is authorized to use and disclose my Confidential Health Information for treatment, payment, and health care operations, to the full extent permitted by and in compliance with the HIPAA Privacy and Security Rule’s governing Protected Health Information.I authorize TUCH and/or its physicians and other clinicians to disclose all or part of my medical or billing records to any insurance carrier or persons employed by such carrier for the purpose of collecting insurance benefits and auditing claims. I further acknowledge that TUCH may utilize the services of a third party Business Associate or affiliated entity for medical account billing and servicing. I hereby indemnify and release TUCH and its physicians and clinicians from any and all responsibility relative to the release of such information.

Clinic Location

First Name

Last Name

Date of Birth

Email

Must be an tulane.edu email address.

Confirm Email

Mobile Phone Number

Gender

Address

City

State

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Tulane Student ID Number

Insurance Billing Information

Insurance Provider

Services I'd like to receive

Flu

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

Based on your medical history, a nurse consultation will be provided at your scheduled appointment to further evaluate whether you are a candidate for some or all of the selected service(s). Please note that the outcome of that consultation may result in not receiving the service(s).

Need help? Contact us at michele@passporthealthlouisiana.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.