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.

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Insurance Billing Information
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Services I'd like to receive
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 michele@passporthealthlouisiana.com