2017 Influenza Vaccine Insurance Information and Consent Form The completion of this form is necessary for every vaccine recipient. If no insurance information is available, please fill out as much as possible using existing information.

Information about the person to receive vaccine (please print): * Required Fields Name: (Last, First, MI)*

Date of Birth:* _____ _____ _____ Month

Day

Age*

Sex: (Circle)* Male

Year

Female

Street Address:* City:*

State:*

Zip:*

Phone:* ( )

-

Insurance Information: Include the whole member ID number and any letters that are part of that number. Name of Insurance Company:*

Member ID Number:*

Group ID Number: (if available)

Medicare Number:

Is Medicare Primary? (Circle) Yes No

Is Subscriber Retired? (Circle) Yes No

If person getting vaccinated is not the subscriber, please complete the following: Subscriber’s Name: (Last, First, MI)*

Subscriber’s Date of Birth:* _____ _____ _____ Month

Day

Sex: (Circle)* Male

Year

Female

Subscriber’s Street Address:* (If different from address above) City:*

State:*

Patient relationship to Subscriber: (Circle)*

Spouse

Child

Zip:*

Phone:* ( )

-

Other:

Subscriber’s Employer:

I give permission to receive vaccine and for my insurance company to be billed. X _____________________________________________________

Date: ___________________

(Signature of patient, parent, or legal guardian) ******** Clinic/Office Use Only:***************************************************************************************** Complete highlighted sections Vaccine

Fluzone

Mnfr

Sanofi

Lot/Exp (place sticker)

State (circle)

Y

Preserv Free

Dose

Route

Y

0.5ml

IM

Site (RA,LA,RT, LT)

Date on VIS

8/7/15

N

Date VIS Given

Initials of Vaccine Administrator: X_________________ Date Administered:

For Children 18 years of age and younger: VFC (Vaccines for Children) eligible: o Enrolled in Medicaid (includes MassHealth and HMO’s etc if enrolled through Medicaid) o Does not have health insurance o Is American Indian (Native American) or Alaska Native If not VFC eligible: Has health insurance and is not American Indian (Native American) or Alaska Native Provider Name: North Andover Health Department Provider Address: 120 Main St, North Andover MA 01845 o

MDPH Provider PIN#: 11187