Patient Information

My First Name
Middle Initial
My Last Name
DOB
Mobile Number
Email
Password
What sex were you assigned at birth?	Select an Option Female Male Neither Female nor Male Unknown Prefer not to answer
How do you identify your gender?	Select an Option Woman Man Transgender Woman Transgender Man Non-binary person Genderqueer person A gender identity not listed Unknown Prefer not to answer
Street Address
Apt/Suite
City
State	Select a State New York Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
County	Select a County Albany Allegany Bronx Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Kings (Brooklyn) Lewis Livingston Madison Monroe Montgomery Nassau New York (Manhattan) Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Queens Rensselaer Richmond (Staten Island) Rockland Saint Lawrence Saratoga Schenectady Schoharie Schuyler Seneca Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates Outside of NY State
Zip Code
What race do you identify as?
Do you identify as Hispanic, Latino or Latina?
Physician Name
Physican Contact Number
If the person receiving the vaccine is under 18 years old, please check here to provide parental or guardian consent:
Parent/Guardian Name

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Health Insurance

COVID-19 vaccinations are free for you ! Insurance is not required, but if you have insurance, the vaccine provider will bill your insurance company for an administration fee. You will not be charged a copayment.

Do you have health insurance?	No Yes
Would you like to enter health insurance information now?	No Yes
Type of Insurance Select an Option Medicaid Medicare Private Insurance Uninsured	Company Name	Recipient ID Number	Beneficiary ID Number
Plan Name Select an Option Medicaid Medicaid Out Of State of New York Other	PCN
BIN	Effective Date of Coverage
Effective Date of Coverage	PCN
BIN
Plan Name	* Member ID Number
Group Number	PCN
BIN	Relationship To Policyholder Select an Option Self Spouse Child Other
Policyholder's First Name	Policyholder's Last Name
Policyholder's Date of Birth	Effective Date of Coverage

Please download VIPHealth to manage your COVID-19 vaccination appointment.

To access VIPHealth app, please scan QR code below, or search "VIPHealth" in App Store/ Google Play.

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