Pediatric Vaccination Medical Authorization Release Form

For Child Insurance Policies

Child's Full Name

Date of Birth

Policy Number

Insurance Provider

Parent/Guardian Full Name Relationship to Child Contact Phone

Vaccinations Authorized

Measles, Mumps, and Rubella (MMR)

Polio

DTaP (Diphtheria, Tetanus, Pertussis)

Hepatitis B

Varicella (Chickenpox)

Hib (Haemophilus Influenzae type b)

Other

Provider/Clinic Name Provider/Clinic Address Provider/Clinic Phone

I, the undersigned parent or legal guardian, hereby authorize the medical provider identified above to administer the selected vaccinations to my child named above. I authorize the release of relevant vaccination and medical records to the insurance provider for policy administration and claims processing. I attest that I have the legal authority to consent to medical treatment for this child.

Parent/Guardian Signature

Date