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Required Forms & Important Information - UFT

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Required Forms & Important Information

provider vaccine forms

United Federation of Teachers members can schedule COVID-19 vaccines with ACPNY

Before you can receive your COVID-19 vaccine, please review the following important information. Required forms must be completed and brought with you to your appointment.

Completing these forms and bringing the proper identification will allow you to ‘fast track’ once you arrive.

  1. New York State COVID-19 vaccine consent form: Please print out this consent, review and sign it. You should bring the completed form to your appointment. Please note: this is separate from any ACPNY specific forms you may complete.
  2.  New York State Eligibility Form: Once you complete this on-line form, it will ask if you want to receive an email confirmation. Please indicate ‘yes’ and bring this email confirmation with you. An email confirmation of this form will look like this. Or alternatively, you can print out a copy of the confirmation and bring it with you. A printed copy of the confirmation will look like this. You must show completion of this form when you arrive for your appointment.
  3. Moderna Vaccine EUA Fact Sheet for Patients: This contains important information about the vaccine.


*What is Fast Track?

Fast track means that you will be able to quickly move through the check-in process prior to receiving your vaccine. To get fast tracked you will need to ensure you have the following:

  • Completed and printed vaccine consent form
  • An email, screenshot or print out of the completed NYS eligibility form
  • NYS ID
  • Your insurance card

Please note: We are not providing the Moderna fact sheet on-site – this can be found in bullet #3 above. 

If you don’t have the above items upon arrival, you will be required to fill out all necessary paperwork on-site before we can properly check you in.

AdvantageCare Physicians Vaccination Details 

Following your COVID-19 vaccine, you will be required to remain in the office for 15-30 minutes. Our nursing team will observe you and assess for any serious adverse reactions.  These are rare.  During the observation period, you will receive your Moderna vaccine card and the team will assist you in scheduling your second vaccine appointment.

In addition to completing and bring the necessary forms, please enroll in v-safe. This is a CDC smartphone-based tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccination. Through v-safe, you can quickly tell the CDC if you have any side effects after getting the COVID-19 vaccine. Depending on your answers, someone from CDC may call to check on you. And v-safe will remind you to get your second COVID-19 vaccine dose at the right time.