School Vaccine Consent Form - Renville County (Page 2 of 2) in pdf

School Vaccine Consent Form - Renville County Page 2

Payment Information: Complete for children receiving vaccination.

Renville County Public Health Services will be billing the following:

Medical Assistance or PrimeWest ID #_________________________________________

MN Care ID # _________________________________________________

Blue Cross Blue Shield Subscriber ID#_____________________________

Insurance Subscriber Name____________________________________

Other Insurance (If you have other insurances other than those above, please provide us with a

photocopy of your insurance card, if possible.)

Company Name________________________________________________

Insurance Subscriber Name______________________________________

ID #________________________________________

No Insurance / underinsured. Checks payable to “Renville County PHS”. Donations encouraged in

these amounts:

_____ $20 for each Tdap vaccination administration (federal government supplying vaccine)

_____ $20 for each MCV vaccination administration (federal government supplying vaccine)

_____ $20 for each HPV vaccine administration (federal government supplying vaccine)

For Office Use only – Check location site of school located vaccination clinic for this student:

BLHS High School, 220 3

Street West, Hector, MN 55342

Cedar Mountain High School, 310 Somerville, Morgan, MN 56266

BOLD High School, 701 South 9

Street, Olivia, MN 56277

BOLD Elementary and St. Mary’s, 110 South 9

Street, Bird Island, MN 55310

RCW Schools, 301 NE 3

Street, Renville, MN 56284

f:\common file\dp&c\school located vaccines 2013-14\2014 slv consent form tdap, hpv & men .docx

School Vaccine Consent Form - Renville County Page 2