COVID-19 Vaccine Consent to bill insurance

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Payment
There is no charge for the vaccine to you. By completing this form, you are providing consent for PHMP to bill your insurance for the administration of the COVID vaccine.
Insurance 1
Choose a payment method*
- I am a current customer of PHMP and my updated 2021 insurance is already on file
- Commercial Insurance
- Medicare Part D/ Medicare Advantage
- I do not have insurance
Insurance Carrier*
Please upload a photo of your insurance card here. Front and back of card is needed.*
Insurance 2
Choose a payment method
- I am a current customer of PHMP and my updated 2021 insurance is already on file
- Commercial Insurance
- Medicare Part D/ Medicare Advantage
- I do not have insurance
Insurance Carrier
Please upload a photo of your insurance card here. Front and back of card is needed.

Payment