With Preservative Without Preservative Paid cash/check Employee BCBS
2016-17 SEASONAL (Temporal)
INFLUENZA CONSENT FORM FORMULARIO DE CONSENTIMIENTO PARA LA VACUNA DE LA INFLUENZA
Statement of Understanding, Permission, and Agreement Declaración de Entendimiento, Permiso, y Acuerdo
Last Name
First Name
MI
(Apellido)
(Primer Nombre)
(Segunda Inicial)
Social Security Number (Número de Seguro Social)
Date of Birth Race (Fecha de Nacimiento) (Raza)
Address (Dirección)
Medicare Number
Sex: Male
Female
Age
(Sexo) (Masculino) (Femenino)
(Edad)
Telephone # (Numero de Teléfono)
(Copy Front & Back of Insurance Card & Attach to Form)
(Número de Medicare)
Insurance Name: (Nombre de Aseguranza)
Policy # (Número de Póliza)
Address: Medicaid Number
(Dirección)
(Número de Medicaid)
STATEMENT OF UNDERSTANDING: I have read and I understand the information provided to me about receiving vaccines for influenza, and I have had the opportunity to ask questions. I understand that being allergic to eggs may be a reason for not receiving the influenza vaccine. I affirm to the best of my knowledge that the following questions have been answered truthfully: DECLARACIÓN DE ENTENDIMIENTO: He leído y entendido la información presentada acerca de la vacuna de la influenza y he tenido la oportunidad de Hacer preguntas. Entiendo que ser alérgico al huevo puede ser razón para no recibir la vacuna de la influenza. Yo afirmo con conocimiento que la pregunta siguiente ha sido contestada sinceramente:
1. 2. 3. 4. 5. 6.
Are you allergic to eggs? Es usted alérgico/a al huevo? Have you had a serious allergic reaction to Influenza Vaccine? Ha tenido una reacción alérgica a la vacuna de la influenza? Do you have history of Guillain-Barre’ Syndrome? Tiene Usted un historial de síndrome de Guillain-Barre? Do you have a fever with a temperature above 100? Tiene usted fiebre más de 100 gradas de temperatura? Do you have asthma? Tiene usted Asma? Do you have a latex allergy? Tiene usted alergia al latex?
Circle Yes or No Circule Si o No Yes No Sí
Yes Sí
Yes Sí
Yes Sí
Yes Sí
Yes Sí
No
No No
No No
No No
No No
No No
Continued on next page continua en página siguiente
STATEMENT OF PERMISSION AND ASSIGNMENT: I voluntarily give my permission to receive the influenza vaccine. I understand that payment for this service may be made in accordance with the provisions of Title XVIII of the Social Security Act (Medicare), and/or Title XIX of the Social Security Act (Medicaid); and/or private insurance or other third-party payor. I hereby authorize the provider of service to release information necessary for the processing of any claim for payment made on my behalf, and I authorize payment to the provider for such claim I understand that I am responsible for any costs incurred that are not covered by a third-party payor.
DECLARACIÓN DE PERMISO Y OBLIGACIÓN: Doy permiso voluntariamente para recibir la vacuna de la influenza. Entiendo que el pago por este servicio puede ser en acuerdo a las disposiciones del título XVIII del acto de Seguro Social (Medicare, y/o título XIX del acto de Seguro Social (Medicaid); y/o Aseguranza Privada u otro reclamo de pago hecho en nombre suyo, y autorizo pago al proveedor de dicho reclamo Entiendo que soy responsable por cualquier costo que no sea pagado por Medicare, Medicaid o Aseguranza Privada.
Signature (Firma)
Date (Fecha)
Para uso del proveedor solamente ----------------------------------------------------------------------------------------------------------------------------- -----------For Provider Use Only: Influenza Vaccine Mfgr: Lot #: Expires: 6/30/2017 Injection Site: Right Left Deltoid Administered by: Date:
State Supplied Uninsured child ≤ 18 years old Medicaid child ≤ 18 years old American Indian/ Alaskan Native CCHD Family Planning/Medicaid Uninsured Maternity
ATTENTION RN: PLEASE INFORM CLIENT THAT Two doses given at least four weeks apart is recommended for children aged 6 months through 8 years of age who are getting a flu vaccine for the first time.
vaccines for influenza, and I have had the opportunity to ask questions. I understand that ... reason for not receiving the influenza vaccine. I affirm to the best of ...
Do you have history of Guillain-Barre' Syndrome? Yes. No. Tiene Usted un historial de síndrome de Guillain-Barre? Sí. No. 4. Do you have a fever with a ...
Have you had a serious allergic reaction to Influenza Vaccine? Yes. No ... responsible for any costs incurred that are not covered by a third-party payor.
Por favor marcar el proveedor de seguro a continuación: Please check health insurance provider below: Medicaid. Aetna. TRICARE Standard ONLY. Peachcare.
23 jul. 2018 - by Texas Education Code Section §22.083. I understand that the age, sex, and ethnic information is required by the Texas Department of Public ...
As parent/guardian, I understand that promotional pictures and videos (individual and ... Concedo permiso para que la fotografía de mi hijo(a) sea utilizada en ...
Student Race: (Circle one) African American / Black White Alaskan/ Native American ... AREA FOR OFFICIAL ADMINSTRATION USE ONLY. VIS CDC IIV 08/15/ ...
trabajo, y a mi familia. Hasta las personas sanas pueden contraer la influenza, y puede ser grave. Para más información en español visite: http://www.cdc.gov/flu ...
I request and authorize that school personnel administer this medication at school ... I will obtain a new physician's order and notify the school with any changes ...
Una vez que la información del menor esté en ImmTrac2, por ley la puede acceder: • el distrito de salud pública o el departamento de salud local, para propósitos de salud pública dentro de sus áreas de jurisdicción;. • el médico, o algún otro médico
to this release of information by giving notice to IU Health Physicians in writing. Health Insurance Portability and Accountability (HIPAA): I acknowledge that I ...
finely shredded wool from one end to the other evenly. Aligna los brazos y con firmeza enrolle de un extremo al otro el hilo o la lana deshebradade manera.
Biología ADE, Honores Aprobados en Biología ADE, o Crédito Concurrente de Biología). • Ciencia Física, Química o Física - al menos 1 unidad. Estudios ...
ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure.
Mother's Maiden Name. ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The immunization ...
los grados 4K-8vo no pueden llevar o auto-administrar medicamentos por la política ... Elijo permitir que mi estudiante 9-12 grado de llevar y autoadministrarse ...
Security Administration or its intermediaries or carriers, or to the billing agent of anesthesia claims or suppliers, any information needed for this or a Medicare ...
22 ago. 2016 - Chew on This: Everything You Don't Want to Know About Fast Food by Eric. Schlosser and Charles Wilson ..... Grade 12: Theory of Knowledge.