Jackson County Public Health (JCPH) is managed and operated by University Health (UH).
Vaccine Authorization and Consent: I have been given a copy and have read or had read to me the Vaccine Information Statements (VIS) for each vaccine that I am requesting to be given to the person named on the form. I give permission for the above named patient to receive the American Academy of Pediatrics recommended vaccinations and as indicated by my vaccine selections.
Personal Financial Responsibility: By signing this form and in return for the services rendered by JCPH, UH and the Physicians, I acknowledge that I have reviewed the list of managed care plans accepted by Jackson County Public Health (JCPH) and that I am personally responsible for all UH fees and physician fees not paid by any third party on my behalf.
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 JCPH, UH, UH physicians and/or University Physician Associates. I agree that UH 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 Public Health, University Health, and/or University Physician Associates.
Notice of Privacy Policy: I have reviewed a copy of the Notice of Privacy Policy that can be found here: https://res.cloudinary.com/dpmykpsih/image/upload/truman-site-261/media/6755ae67f19d4e18b99c270058881b2a/uh_notice-of-privacy-practices_poster_2026.pdf
