Kanawha-Charleston Health Department

108 Lee Street, East, Charleston WV 25301

Immunization Clinic Registration
Section A
Patient’s Name _____________________________________________________________________________________
(Last) (First) (Middle)

Current Address ____________________________________________________________________________________

(Street Address) (City) (State) (Zip)

Date of Birth ____________ Age ______ Race _______ Gender _____ Last 4 digits of Social Security #_________
Home Phone # __________________ Cell Phone #________________ E-Mail _________________________________
Is the patient a college student? Yes No
If the patient is a college student, will they be living on campus? Yes No
If the patient is a college student, are they a student in a healthcare program? Yes No

Section B
Children 18 and under and college students living on campus may qualify for state-supplied vaccine at a reduced rate. If the patient
is 18 or under, please complete this Section of the form. If the patient is 19 or older, please skip to Section C

Parent/Guardian ___________________________________________________________________________
Last name First MI
This child is privately insured Yes No
This child is enrolled in WVCHIP and qualifies for state-supplied vaccine Yes No
This child qualifies for Immunization through the VFC Program because he/she (check only one):
Is enrolled in Medicaid
Does not have health insurance
Is an American Indian or Alaskan Native
Is underinsured (has health insurance that does not pay for vaccinations)
Primary Physician’s Name____________________________________________________________________________________
Last name First MI

Section C
ACKNOWLEDGEMENT OF THE NOTICE OF PRIVACY PRACTICES
The KCHD Notice of Privacy Practices provides information about how we may use and disclose your protected health information. By signing this
form, you acknowledge that the KCHD Notice of Privacy Practices was made available to you. The Notice of Privacy Practices is subject to change.
If we change our Notice, you may obtain a copy of the revised Notice by visiting our website at www.kchdwv.org or on request from KCHD.
CONSENT
You must be at least 18 years of age to sign. If under age 18, a parent’s signature is required. If you are a legal guardian, guardianship
papers must also be provided. By signing, you are stating the following for each vaccine selected: Vaccine Information Statements (VIS Forms)
have been made available to me and I understand the information about the vaccine(s) I have chosen. I understand the benefits and risks of the
vaccine(s) as well.
PAYMENT INFORMATION
Option 1: Pay the day of the clinic.
Cash, check, MasterCard, VISA, and Discover credit/debit card payments may be made on the day of the clinic.

Option 2: Bill Insurance. Kanawha-Charleston Health Department can bill the insurances listed below for the immunizations.
Submission of insurance information does not guarantee that the insurance company will cover the vaccines given. If the insurance company
does not cover the vaccines, the parent or legal guardian will be responsible for the charges.

Please indicate your method of payment – Option 1 Option 2 - For Option 2, complete the following:
Primary Insurance: PEIA Carelink Medicaid Chips Unicare Blue Cross/Blue Shield
Policy Patient Relationship
Holder’s Name ________________________________________________________ To Policy Holder _______________________
(Last) (First)

Policy Holder Date of Birth:_________________ Policy ID Number: ____________________ Group # (if any) _________________

X___________________________________________________________ __________________________________
Signature of Patient or Patient’s Representative Date