I hereby give my consent to the health care provider of The Kroger Co., its affiliates and subsidiaries, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the vaccine(s) being administered and have received, read and/or had explained to me the CDC’s Vaccine Information Statement (VIS) or the FDA’s Emergency Use Authorization (EUA) on the vaccine(s) I have elected to receive. I have had the opportunity to ask questions that were answered to my satisfaction. As with all medical treatment, there is no guarantee that I will not experience an adverse reaction from the vaccine. I understand that the information contained on this form may be shared with the Stated Health Division (SHD) and/or state immunization registries and will remain confidential and will not be released except as permitted or required by law. If eligible, I authorize Kroger to submit a claim for reimbursement on my behalf to Medicare or any other contracted third party payor. If the claim is denied, I understand that I will be responsible for payment. I understand if my claim to the HRSA Uninsured Fund is not reimbursed because it is determined that I have third-party insurance, I authorize The Kroger Co. to utilize my protected health information and other identifiers to try to identify and bill my insurance. I acknowledge that I have received a copy of the Notice of Privacy Practices. Furthermore, I agree to remain near the vaccination location for approximately 15-30 minutes after administration for observation by the administering Healthcare Provider.
