Pharmacist Immunization Inputting Form For Patients Without A Valid Phin

ADVERTISEMENT

Pharmacist Immunization Inputting Form for
Patients without a Valid PHIN
Use this form to record the immunizations given at your pharmacy to patients without a valid personal health
identification number (PHIN) only. Please include the client’s place of residence and their Provincial health card
th
number, if from Canada. Please fax this form to Manitoba Health, on or before the 5
day of the month after each
quarter (April, July, October, January) to ensure prompt compensation. Computer generated inputting forms will be
accepted as long as all of the information requested on this form is included.
Please record all other immunizations given at your pharmacy to the Drug Programs Information Network (DPIN),
submitted for Drug Utilization Review (DUR) under a patient’s valid Personal Health Identification Number (PHIN).
Administering Pharmacy Contact Information
Pharmacy Name:
Provider Number: P __ __ __
Address:
City / Town:
Postal Code:
Certified Pharmacist Name:
Registration Number:
__________________________________________________________________________________________
Telephone: ( __ __ __ ) __ __ __ - __ __ __ __ Fax: ( __ __ __ ) __ __ __ - __ __ __ __
FOR BRANCH
Client Name and Date of Birth
Place of Residence/
Vaccine
Tariff
Date Given
USE
Provincial Health
Card Number
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Entered 
Funding 
Y Y Y Y
/
M M
/
D D
_ _ _ _
Y Y Y Y
/
M M
/
D D
Submit to Manitoba Health Secure Fax: 204-948-2190

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Pharmacist Immunization Certification Form - Application For Certification - New York The State Education Department Pharmacist Immunization Certification Form - Application For Certification - New York The State Education Department Legal
Form L2 - Requests For Overrides, Reductions, Or Waivers Of Civil Penalties For Work Without A Permit And Stop Work Order Violations Form L2 - Requests For Overrides, Reductions, Or Waivers Of Civil Penalties For Work Without A Permit And Stop Work Order Violations Legal
Form Dcd-0335a - Subsidized Child Care Input Form For Dpi Certified Child Care Program Form Dcd-0335a - Subsidized Child Care Input Form For Dpi Certified Child Care Program Legal
Form P46 - Employee Without A Form P45 Form P46 - Employee Without A Form P45 Business
Form P46 - Employee Without A Form P45 Form P46 - Employee Without A Form P45 Financial
Form P46 - Employee Without A Form P45 - 2006 Form P46 - Employee Without A Form P45 - 2006 Financial
Form P46 - Employee Without A Form P45 - Hm Revenue And Customs Form P46 - Employee Without A Form P45 - Hm Revenue And Customs Financial
Patient Information Form For Patients Under 18 Years Of Age Form Patient Information Form For Patients Under 18 Years Of Age Form Medical
Form Ta-1 - Uniform Form For Registration As A Transfer Agent And For Amendment To Registration Pursuant To Section 17a Of The Securities Exchange Act Of 1934 Form Ta-1 - Uniform Form For Registration As A Transfer Agent And For Amendment To Registration Pursuant To Section 17a Of The Securities Exchange Act Of 1934 Legal
Form Mf 203 - Application Form For License As A Retail Motor Fuel Dealer - Ohio Department Of Taxation Form Mf 203 - Application Form For License As A Retail Motor Fuel Dealer - Ohio Department Of Taxation Financial

Related Categories

Parent category: Medical
Download
Go