We Build Healthier,
Happier Communities.

Completion of the AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION document to authorize the disclosure and/or use of health information about you.

Failure to provide all information requested may invalidate this Authorization.

This authorization is necessary to comply with the terms of the Confidentiality of the Medical Information Act of 1981, Civil Code Section 56 et seq. and the Health Insurance Portability and Accountability Act (HIPAA) of 2003

Download, complete, print, and bring this form to a Neighborhood Healthcare site. Requests may take up to two weeks to process.

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION (FROM)
AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION (TO)

A vaccine is a product that stimulates your immune system to produce antibodies, exactly like it would if you were exposed to the disease. After getting vaccinated, you develop immunity to that disease, without having to get the disease first. This is what makes vaccines such powerful medicine. Unlike most medicines, which treat or cure diseases, vaccines prevent them.

You can reduce your risk of infection, disease, hospitalization, severe complications, and even death by getting vaccinated. The early results for the vaccine clinical trial indicate 74-95% efficacy at preventing COVID-19 symptoms.

The U.S. Food and Drug Administration (FDA) has authorized the COVID-19 vaccines emergency use in individuals 12 years of age and older.

There will be no cost associated with the COVID-19 vaccine.

Yes. If you’ve tested positive for COVID-19, you are still eligible to receive the vaccine.

As a friendly reminder, COVID-19 vaccination is recommended for pregnant people. The CDC continues to recommend COVID-19 vaccination for all people aged 12 years and older, including people who are pregnant, recently pregnant (including those who are lactating), who are trying to get pregnant now, or who might become pregnant in the future.

CDC recommendations align with those from professional medical organizations serving people who are pregnant, including the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.

For more information regarding vaccination while pregnant, breastfeeding, or lactating, click here.

Our vaccinators are trained to administer the COVID-19 vaccine will monitor you for side effects for at least 15 minutes after receiving your vaccine. Any vaccine can cause mild side effects. The ones identified with the COVID-19 vaccine may include but are not limited to, pain at the injection site, tiredness, headache, muscle pain, joint pain, and fever. Of note, more people experienced these side effects after the second dose than after the first dose. In most cases, discomfort from fever or pain is normal. Contact us if redness or tenderness where you got the shot increases after 24 hours or if your side effects are worrying you.

Neighborhood Healthcare is a Federally Qualified Health Center providing a wide range of medical, dental, and behavioral health services, along with programs and resources designed to improve the health and happiness of the communities we serve. Our mission is to provide quality care to every member of our community, regardless of situation or circumstance. As a private, non-profit 501(C) (3) community health organization, we serve 414,995 medical, dental, and behavioral health visits from 87,099 people annually.

Neighborhood Healthcare offers a wide range of quality health care and wellness services including Primary Care, Behavioral Health, Dental Care, Women’s Health, Pediatrics, Chiropractic, Podiatry, Acupuncture, Vision, Tattoo Removal, Pharmacy, Laboratory, and more. For descriptions and locations that offer services, visit our Services page.

Visit our Locations page for services, to find a doctor, hours of operation, and directions for each of our locations throughout San Diego and Riverside counties.