Claim/consent Form For Vaccination printable pdf download

U of W Insurance Claim Form

and Consent: Influenza Immunization

UMP, Group Health, GAIP and SHIP accepted

________

Please check insurance plan:

Uniform Medical Plan of Washington

Group Health

Medicare Part B

Graduate Appointee Insurance Program (GAIP)

Student Health Insurance Plan (SHIP)

For use by U of W employees & covered dependants

Group Health members under non-state plans may not be covered for

And covered students

flu vaccinations

Patient Information (PLEASE PRINT)

(middle initial)

MI:

Last Name:

First Name:

Insurance ID#

Member ID Number:

(Month/Day/Year)

Date of Birth: _______________________________________________________

Sex:

Mailing Address:

City:

State:

ZIP Code:

Phone #: (___________)

___________ - ______________________________

Insured’s ID Number (if different from above):

Relationship to Patient:

Have you ever had a severe reaction to a flu shot?

Yes

Are you allergic to eggs?

Yes

Do you have a history of Guillain-Barre Syndrome?

Yes

If female, are you pregnant

Yes

Are you allergic to latex?

Yes

I have read/had explained to me the Vaccine Information Statement about influenza and influenza vaccine. I have had a

chance to ask questions and had them answered to my satisfaction. I believe I understand the benefits and risks of influenza

vaccine and ask that the vaccine be given to me or to the person named above for whom I am authorized to make this

request. I agree that neither nor its sponsor or host site shall have any responsibility or liability if I

contract influenza or other respiratory diseases, or suffer any other adverse reaction, following administration of the flu

shot. I understand that I am responsible for payment for the vaccine if my insurance carrier denies payment.

: __________________________

Signature

: ____________ Date: ___________

of responsible person

Relationship

Community Provider/Health Plan Use Only

Clinic Use Only

Federal Tax ID: 91-1754065 Service Location: 60

Clinic Location: ______________________________________

NPI # 1528244282

CPT Code (vaccine): 90658

CPT Code (admin): 90471

Date of Vaccination: __________________________________

Diagnosis Code: V04.81

Mfg/Lot #: ___________________ Expiration Date: __________

Nurse’s Initials: ___________ Site of Injection: L R Deltoid

Charge: __________

Please remit to:

(503) 258-9800

(877) 358-7468

135 SE 102

Ave

(503) 258-8311 fax

Portland, OR 97216

GAFS 08/11

8/1/03

Claim/consent Form For Vaccination

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