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Parent Flu Consent

Please fill out this form as completely as possible. It will be sent securely to our office.

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Advance Beneficiary Notice

Your healthcare insurance may not pay for the influenza vaccine. Health insurers do not necessarily pay for all of your health care costs. Insurance only pays for covered items and services. The fact that insurance may not pay for a particular service does not mean that you should not receive the service especially if your physician recommends that you have it. If you have an insurance that requires you to elect a PCP, we will not file your insurance for you. You will be required to pay out of pocket at time of service.

The purpose of this form is to help you make an informed choice about whether or not you want to receive thus service, knowing that you might have to pay for it yourself. As a courtesy our office will file this service to your Insurance company. If our office should not receive payment for this service from your insurance company, you will receive a statement for the outstanding balance.


Who should NOT get an influenza vaccine? Talk to your healthcare provider before getting an influenza vaccine if you:

1. Have you ever had a severe allergic reaction to eggs?*
2. Have you ever had a serious reaction to a previous influenza vaccine?*
3. Have you ever had Guillain-Barre’ Syndrome (a severe paralytic illness, also called GBS) that occurred after receiving the influenza vaccine?*
4. Are you or anyone you are in direct contact with immunosuppressed or pregnant?*

If you are sick with a fever at the time you plan to receive the influenza vaccine, you should discuss with your healthcare provider possibly delaying the administration of the vaccine. However, you can get an influenza vaccine at the same time you have a respiratory illness without a fever or if you have another mild illness.

Consent and Signature

I request that payment of authorized commercial insurance benefits be made to Fairhope Pediatrics, Inc., for any service furnished to me by Fairhope Pediatrics’ providers. I authorize Fairhope Pediatrics, Inc., to release medical information which may be required by my insurance carrier to determine payment for services rendered. I further understand that I am responsible for paying certain amounts due to the provider. These amounts could include annual deductibles, co-payments, coinsurance, charges denied as not covered by my commercial insurance carrier, and charges denied for services determined as not medically necessary. I further understand that if Fairhope Pediatrics, Inc., incurs any fees associated with collecting payment on my account, I will be responsible for paying all of those fees.
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