Skip To Navigation Skip To Content Skip To Footer
      Practice Fusion from Veradigm: Top 10 reasons for claim denials - See the full list
      Member Tool

      Form: Refusal to Consent to Vaccination (Pediatrics)

      Home > Member Tools
      Generic profile image
      MGMA Staff Members

      This member-benefit sample form is a tool for practices to document refusal to consent to vaccination in a pediatric patient's medical record. It is not a waiver form; contact your local health department for more information.

      Sign in to access this material

      Sign In Become a Member
      Generic profile image

      Written By

      MGMA Staff Members


      Practice Fusion from Veradigm: Top 10 reasons for claim denials - See the full list

      Explore Related Content
      Patient experience survey

      Member Tool

      Patient Experience Survey Template

      No-show

      Member Tool

      Oncology Patient No-Show Policy

      Generic profile image

      Catherine Wallace

      Insight Article

      Breaking barriers in cancer care

      Generic profile image

      Young doctor typing

      Member Tool

      How to customize a patient discharge letter

      Generic profile image

      Member Tool

      Form: Refusal to Consent to Vaccination (Adults)

      Generic profile image

      Insight Article

      Patient satisfaction starts with effective, efficient communication

      Supply and Drug Costs

      Insight Article

      Improvements to Supply and Drug Costs

      Generic profile image

      Overhead costs

      Insight Article

      Assessing and Managing Administrative (Overhead) Costs

      Generic profile image

      1. Operational excellence 2. Data-driven accountability system 3. Organizational alignment 4. Financial optimization 5. An engaged workforce 6. Physician governance and leadership 7. High-performance culture

      Insight Article

      7 essential components of a high-performing physician enterprise

      Generic profile image

      Figure 1 - A patient experience flowchart

      Insight Article

      The system worked, but... Recognizing gaps in care delivery and improvement opportunities

      Generic profile image

      Online Course

      Lean Six Sigma Green Belt Certificate

      ICE - Immigration

      Insight Article

      When ICE shows up at your clinic or hospital

      Generic profile image

      Podcast

      Mindful Medicine: Resilience on Everest and in healthcare with Dr. Mimi Zieman

      Generic profile image

      Podcast

      Member Spotlight: Sula Coria-Garza on unlocking healthcare solutions with networking and technology

      Generic profile image

      Kelly Smith

      Podcast

      MGMA Insights: Creating compassionate and productive workplaces with Kelly Smith

      Generic profile image

      MGMA Stat

      Patient no-shows holding steady at medical groups in 2023

      Generic profile image

      Staples whitepaper: Prepare your medical practice for flu season with 6 key tips

      Sponsored Solution

      New report: 6 Strategies to Keep Your Practice Running Efficiently During Flu Season

      MGMA Stat

      No-show fees in medical practices on the rise to balance bumpy attendance rates

      Generic profile image

      Unlocking the Potential of AI - Elation Health

      Sponsored Solution

      Are You Ready to Unlock the Potential of AI in Your Practice?

      Patient and provider

      Member Tool

      Provider-Patient Relationship Termination Toolkit

      Generic profile image

      More Member Tools
      Patient experience survey

      Member Tool

      Patient Experience Survey Template

      Mission, Vision, Values

      Member Tool

      Step-by-Step Guide for Developing Mission, Vision, and Values

      No-show

      Member Tool

      Oncology Patient No-Show Policy

      Cristy Good

      Cristy Good

      PM system evaluation

      Member Tool

      Practice Management (PM) System Evaluation Checklist

      Cristy Good

      Cristy Good

      Medical coding

      Member Tool

      2025 HCC Coding Guide for Primary Care

      Physician credentialing

      Member Tool

      Physician Credentialing Checklist

      Provider privileging

      Member Tool

      Provider Privileging Checklist

      A woman holding a clipboard and looking at a man

      Member Tool

      Physician Interview Evaluation Scorecard

      Member Tool

      Job Offer Letter Template

      Root cause analysis

      Member Tool

      Root Cause Analysis Template

      Cristy Good

      Cristy Good

      Young doctor typing

      Member Tool

      How to customize a patient discharge letter

      Cristy Good

      Cristy Good

      ICD-10-CM Coding

      Member Tool

      2025 ICD-10-CM Coding and Reporting Updates

      Veronica Bradley

      Veronica Bradley

      AI

      Member Tool

      Sample Patient Consent Form for Using Artificial Intelligence for Dictation, Transcription

      Cristy Good

      Cristy Good

      A project meeting around a table in an office setting.

      Member Tool

      Healthcare Project Management Toolkit

      Generic profile image

      MGMA Staff Members

      Interviewing

      Member Tool

      Medical Group Interviewing Toolkit

      Generic profile image

      MGMA Staff Members

      Member Tool

      2023 Medical Coding and Billing Toolkit

      Andrew Hajde

      Andrew Hajde

      Member Tool

      How to Use MGMA's Visit Productivity Growth Calculator

      Image coming soon

      Member Tool

      2022 Medical Coding, Billing and Auditing Toolkit

      Image coming soon

      Member Tool

      2022 Medicare Physician Fee Schedule (PFS) Tool (Non-facility)

      Andrew Hajde

      Andrew Hajde

      Image coming soon

      Member Tool

      2022 Medicare Physician Fee Schedule (PFS) Tool (Facility)

      Andrew Hajde

      Andrew Hajde

      Explore Related Topics

      Policies & ProceduresOperations ManagementPatient Engagement
      Ask MGMA
      An error has occurred. The page may no longer respond until reloaded. Reload 🗙