JACOHD Immunizations: September 21

JACOHD Immunization Clinic

This is for immunizations at the Jackson County Health Department in Missouri. If you are looking for a different Jackson County health department, please consult their website.
THIS FORM IS NOT FOR COVID-19 VACCINATIONS

Where: Jackson County Health Department, 313 S. Liberty St., Independence, Missouri 64050

Who: This is open to anyone needing immunizations.

For a list of our available immunizations, please visit https://jacohd.org/clinical-services/immunizations/

Be sure to bring your immunization record/card to your appointment.

For additional dates, please visit www.jacohd.org

This is for immunizations at the Jackson County Health Department in Missouri. If you are looking for a different Jackson County health department, please consult their website.
Appointment Type

Please select your appointment type below
Which immunization services are needed?*

Travel ImmunizationOther Non-travel ImmunizationFlu Vaccine
Appointment

Choose your appointment time and then be sure to write it down. You will NOT be called to confirm your appointment. If you need to cancel or change your appointment time, please call 816-404-6416.
Use the picker to choose your appointment time.*
Patient Information
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Age*
Place of Birth (State)*
Race (Choose all that apply)*

White / CaucasianBlack / African-AmericanAsianNative Hawaiian / Pacific IslanderAmerican Indian / Alaska NativePrefer not to answerOther
Ethnicity*

Hispanic / LatinoNot Hispanic or LatinoPrefer not to answer
Birth Sex*

MaleFemaleUnknown
Gender*

MaleFemaleIndeterminateUnknownOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Will the patient or guardian require interpreter services?*

YesNo
Preferred Language
Email
example@example.com
Information of Responsible Party

Must be at least 18 years of age
Name*

First NameMiddle NameLast Name
Relationship to Client*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Payment and Insurance Information
For required or recommended non-travel vaccinations: If you do not have insurance or if your insurance does not cover vaccinations, there will be a $15 fee for the visit due at the time of the visit. This is a flat fee regardless of how many vaccinations are given. If your insurance is out of our network, you will need to contact your insurance provider to verify your out-of-network benefits.

A list of our in-network insurance plans can be found here: http://jacohd.org/wp-content/uploads/2020/04/2020-Managed-Care-Plan-Listing_updated-2020_1_14.pdf

For travel vaccinations: it's important that you verify your insurance coverage prior to your visit. Many travel vaccinations are not covered by insurance. For travel vaccinations not billed to insurance, you will be charged the cash discount price at the time of service for each vaccine given. The list of prices can be found here: https://jacohd.org/wp-content/uploads/2020/05/Vaccine-Fee-Matrix-02-21-2020.pdf
If this appointment is for travel, to where are you traveling?
Country (required for billing)
Insurance Coverage:*

I have commercial insurance that covers vaccines, and I will list insurance information belowI currently have medicaidI do not currently have insurance or my insurance does not cover the vaccines I need
Medicaid ID
Payment

Please bring a debit or credit card for payment or bring exact change in cash. No checks will be accepted.
Upload a photo of your insurance card:

Browse Files

Cancelof
On a mobile device? Upload a photo of your insurance card:
Name of Primary Health Insurance Company
Policy Number or Member ID
Group Number
Relationship to Insured

SelfSpouseDependent
Policy Holder's Name

First NameMiddle NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's Phone Number

Area CodePhone Number
Policy Holder's Social Security Number
Safety

Please ensure masks are worn to your appointment. Only the client and their guardian will be allowed during the immunization appointment. For safety reasons, you will not be allowed into the facility until your appointment time. If you miss your appointment time, you will need to reschedule.
Immunization Screening Questions

These questions should be answered from the perspective of the patient. A health department nurse will review these questions for accuracy with the patient before immunizations are given.
Are you sick today?*

YesNo
Do you have a fever?*

YesNo
Do you have a food, medication, or vaccine allergy?*

YesNo
Are you allergic to yeast?*

YesNo
Have you ever had a severe reaction to a vaccine, medication, wasp sting? Have you developed an allergic reaction (hives) or wheezing following any of these?*

YesNo
Have you ever had a seizure or convulsion?*

YesNo
Do you have or live with or take care of someone with Cancer, AIDS, or an immune disorder or are you being treated with cancer medications, radiation, or receiving steroid therapy 2 weeks or longer?*

YesNo
Do you take cortisone, prednisone, other steroids or anticancer drugs or have you had any x-ray treatments?*

YesNo
During the past year, have you received a blood transfusion or blood products, or have been given a medicine called immune (gamma) globulin?*

YesNo
Have you had an allergic reaction to latex, eggs, gelatin, or neomycin?*

YesNo
Have you ever had a life threatening reaction to mouse protein or themerosal?*

YesNo
Have you had your thymus removed, had myasthenia gravis, Di George syndrome, or thymoma?*

YesNo
Do you have severe renal impairment?*

YesNo
Have you received any vaccinations in the past 4 weeks?*

YesNo
Questions for Female Patients
Are you nursing, pregnant or is there a chance you could become pregnant during the next month?

YesNo
Are you currently using a birth control method?

YesNo
What is the first day of your last menstrual period?

MonthDayYear
Date
Authorization and Consent
Assignment of Insurance Benefits: I hereby assign all my interest and rights to all insurance benefits, otherwise payable to me from any policy of insurance issued in my name or on my behalf, to JACOHD, TMC, TMC physicians and/or University Physician Associates. I agree that TMC and/or physicians may disclose any portion of my medical, financial or personal information to any person or organization requiring such information as a condition of paying, receiving payment for or justifying payment for my health care or the health care of one for whom I am responsible. I further authorize payment of all insurance benefits, otherwise payable to me, for all treatment provided directly to Jackson County Health, Truman Medical Centers, Inc. and/or University Physician Associates.

Jackson County Health Department is managed and operated by Truman Medical Centers. The notice of privacy practices can be found here: https://www.trumed.org/files/Notice-of-Privacy-Practices-English.pdf My signature indicates that I have reviewed a copy of the Notice of Privacy Policy. Use your mouse or finger to draw your signature below.
Signature of Patient or Legal Guardian*

Clear
Should be Empty:

JACOHD Immunization Clinic

Appointment Type

Appointment

Patient Information

Information of Responsible Party

Payment and Insurance Information

Payment

Safety

Immunization Screening Questions

Questions for Female Patients

Authorization and Consent