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Edmond PS, Student Tdap Clinic
PLEASE SIGN UP FOR AN APPOINTMENT TIME USING PARENT/GUARDIAN CONTACT INFORMATION. PLEASE COMPLETE ONE CONSENT FORM FOR YOUR STUDENT & BRING WITH YOU ON EVENT DAY. PLEASE ALSO BRING A COPY OF YOUR INSURANCE CARD AND/OR YOUR ACTUAL INSURANCE CARD. LIST OF INSURANCE PLANS WE CURRENTLY ACCEPT: 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 & yonuger) 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 SCHEDULING AN APPOINTMENT OR IF YOU HAVE QUESTIONS, PLEASE CONTACT NURSE KIMBERLY AT (405) 563-8961 OPTION 3.
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Services I'd like to receive	Hepatitis B 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.

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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.