Relief Health
Menu
Event Registration
Request Account
Login
LSU Health New Orleans: Vax-up Fall 2021
click here to register an adult
Minor Participant
Participant consents to having their information shared with appropriate state healthcare agencies.
Anticipated vaccinations
Location
---------
Vax-up Fall 2021: LSUHSC Vax-up
Government Issued ID
Covid Vaccination Card
Minor's First Name
Minor's Middle Name
Minor's Last Name
Minor's Email (optional)
Minor's Phone (required if participant is an adult)
Minor's Social Security Number (SSN optional)
Minor's Date of Birth (mm/dd/yyyy)
Minor's Sex
-----
Male
Female
Minor's Race
-----
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Minor's Ethnicity
-----
Hispanic or Latino
Not Hispanic or Latino
Select if you do not have health insurance.
Insurance
Health Insurance
(Other)
AARP Medicare Supplement Plan (36273)
Aetna (60054)
Aetna Better Health of LA (128LA)
All Savers Insurance (81400)
Amerihealth Caritas LA (27357)
Blue Cross Blue Shield (LABLS)
Blue Cross Blue Shield of AR (ARBLS)
Capital Blue Cross (23045)
ChampVA (84146)
Cigna (62308)
Health EZ (41178)
Healthscope Benefits (71063)
Healthy Blue (00661)
Humana (61101)
Kaiser Permanente of N. CA (KPIC1)
LA Healthcare Connections (68069)
Louisiana Medicaid (LAMCD)
Medcost (56162)
Medica Health Plans (94265)
Medicare National
Meritain Health (64157)
Molina Healthcare of CA (38333)
NALC Health Benefit Plan (53011)
Oxford Health Plan (06111)
Physicians Mutual Insurance (47027)
The Loomis Company (23223)
Tricare East (TREST)
Trustmark Insurance (61425)
UMR
United Healthcare (87726)
UnitedHealthcare Community (87716)
WebTPA (75261)
Wellcare (14163)
Health Insurance (Required only if Other was selected above)
Health Insurance Member ID
Health Insurance Group ID
Health Insurance Plan ID (Optional)
Relationship to Person Insured (self, spouse, child, etc.)
Insurance Card Front
Insurance Card Back
Address
Guardian First Name
Guardian Last Name
Guardian Date of Birth (mm/dd/yyyy)
Guardian Email
Guardian Phone
Address1
Address2
City
State
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
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Minor