Insurance Information

The vaccine is available at no cost to you. Insurance information is collected for administrative purposes. Bring your insurance card with you to appointment! If you do not wish to provide your insurance information, select "No Insurance"

Insurance Type/Provider *

If "Other", Specify

Insurance ID # *

Relationship to Recipient *

Enter name of primary subscriber if relationship is not "self" of if name on card differs from recipient name entered above.

Primary Subscriber Last Name

First Name

Middle Name

Primary Subscriber Date of Birth

Primary Subscriber Gender

Enter address of primary subscriber if different than the recipient address entered above.

Primary Subscriber Address

Primary Subscriber City

State

Zip

Monroe County, NY - Vaccine Registration Form

Recipient

Insurance Information

Emergency Contact (optional)

Primary Care Provider (optional)

Screening Questions