COVID-19 Vaccine Contact Registration
for people with I/DD, Caregivers and DSPs

Thank you for your interest in receiving a COVID-19 vaccine. PCC will share information entered below with the Montgomery County Department of Health and Human Services so you can be notified when vaccine appointments are available. Before you complete the registration form, please review the Authorization to Share Information policy below. Submitting the form indicates your acceptance of this policy.

This form is only for residents of Montgomery County Maryland who have an intellectual or developmental disability or provide direct support (paid or unpaid) to an individual with I/DD. Please do not forward this link. 

AUTHORIZATION TO SHARE INFORMATION

Please read the following and complete the information requested.
I permit the Primary Care Coalition of Montgomery County (PCC) to use and share information I have provided to them, including protected health information, with the Montgomery County Department of Health and Human Services.

Personal Information to be Used and/or Disclosed:
I allow PCC to use any health information that I have provided to PCC in connection with the Montgomery County Department of Health and Human Services COVID-19 vaccination efforts. I understand that this information may be seen by people or organizations who are not subject to federal health information privacy laws. 

Right to Revoke: I understand that I have the right to cancel this authorization at any time by writing to PCC at the address listed below. Cancellation will not affect any action PCC took (or any recipients of this information took) before receiving your written notice of cancellation, but will result in no new information sharing.
  • Contact: Hillery Tsumba, Director of Organizational Strategy
  • E-mail: info@primarycarecoalition.org
  • Address: 8757 Georgia Ave, 10th Floor, Silver Spring, MD 20910

Signature
I have had full opportunity to read and think about the contents of this authorization. I understand that, by signing this form, I am giving my permission for the use and/or disclosure of my protected health information, or the protected health information of an individual for whom I am legal guardian, as described in this form. 

The Primary Care Coalition is a 501(c)3 nonprofit organization. Donations to PCC are tax deductible to the fullest extent allowed by law.
​ A copy of our current financial statement is available by contacting the Primary Care Coalition. Documents and information submitted to the State of Maryland under the Maryland Charitable Solicitations Act are available from the Office of the Secretary.