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UT Dallas Flu Vaccination Clinic
UT Dallas is hosting flu vaccination clinics again this year. Please follow the instructions below to register for your location and date. We are able to accept the following PPO insurances: • Blue Cross Blue Shield • Aetna • Cigna* • Humana • United HealthCare • Medicare Part B (provide a copy of any supplement plans also) We are unable to accept HMO plans. We are unable to accept Cigna Local Plus plans. *We are unable to accept Aetna & Blue Cross Gold, Silver or Bronze plans. If you are using insurance for your immunizations you must bring a photo copy of your insurance card and driver's license to the clinic. Your actual driver's license number is not used and can be marked out on your photocopy if you prefer. All other information must be legible on the copy. Most plans cover immunizations at 100%. Please see the consent form for known exceptions. For UT Dallas Employees without one of our accepted insurance plans, UT Dallas will pay for your flu vaccine. Students and retirees without an accepted insurance can pay for a flu vaccine for $23, cash or check only. B12 injections are available for $25 and must be paid by cash or check at the time of service. After you register you will see a confirmation page containing a link to a consent form. Please bring this filled out along with your photo copies. Registration times are requests and not guaranteed. You should still expect a short wait during the clinic. Face masks are optional, but strongly encouraged. Vaccinations are given in the upper arm. Please wear clothing on the day of your clinic that lets this area be easily accessible. Depending on insurance carrier, claims may be filed as Staying Healthy Medical Services or Community Health and Immunization Services. Thank you.
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Services I'd like to receive	Flu Shot Injection Vitamin B12

You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.

Need help? Contact us at info@stayinghealthymedical.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.