In-School Participation Submission Form Insurance Card Submission X/TwitterThis field is for validation purposes and should be left unchanged.Please complete each section and 'Submit'. Thank you for helping us further our mission!Patient Name(Required) First Middle Initial Last Patient's Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Required Health Insurance Information:Select One(Required) Private Insurance Military/Veteran Coverage Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise) No Insurance: I certify that the patient is not covered by any health insurance. Insurance Company(Required)Member ID(Required)Group #(Required)Policy HolderName First Middle Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to Patient(Required)Select OneSelfSpouseChildOtherGrandparentGrandchildNephew or NieceFoster ChildWardStepson or StepdaughterEmployeeHandicapped DependentSponsored DependentDependent of a Minor DependentSignificant OtherMotherFatherEmancipated MinorLife PartnerSocial Security #(Required)Enter the SSN Policy Holder(Service Member or Veteran)-We cannot process claims without it. Thank you!Upload a Clear Insurance Card Image (Front)(Required)Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB. Please take a clear photo of the front of the patient's Insurance CardUpload a Clear Insurance Card Image (Back)(Required)Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB. ConsentConsent(Required) I agreeAll information I have provided on the consent for vaccination is true and correct. I have legal authority to consent for all vaccination services rendered. I consent to my child, named above, to receive in-school Influenza clinic services from Super Shot. I am aware of the HIPAA Notice of Privacy Policy available at supershot.org. I am aware and understand the CDC Vaccine Information Statements for the vaccines the patient will receive today available at https://www.cdc.gov/vaccines/hcp/vis/index.html I give permission to Super Shot to give the patient vaccines indicated in my absence and use all information provided to communicate with other healthcare providers or other entities as needed, for data entry, billing, and storage according to Indiana Department of Health policies. By signing below I agree to the payment option indicated for services performed. I understand that a claim will be filed to my insurance company for vaccination services rendered. Parent/Guardian Name(Required)
