Flu Shot Registration Form (South Carolina) printable pdf download

Flu Shot Registration Form (South Carolina)

Flu Shot Registration Form

Terms and Conditions

Please bring your insurance card with you the day of the flu shot. Your

insurance card ID number will be required when filling out paperwork.

Dependent children are not eligible.

If Medicare or Tri-care is your primary insurance, you are not eligible.

: ______________________________________________

Name

Print Name

Date of Birth: ________________________

Home Address: _____________________________________________

City: _____________________ State: ____________ Zip: _________

Work Phone: ___________________ Home/cell: _________________

My primary insurance is: __ State Health Plan __ BlueChoice __ Cigna

I am an: ___Employee __ Covered Spouse __ Retiree

If you are a covered spouse, please give your spouses first name: ______________

I hereby certify that I am an employee, covered spouse or retiree with insurance coverage

through the state of South Carolina and that I have read the terms and conditions listed

above. I affirm that the information I have given is true and correct. Any discrepancy

may result in further billing by the provider.

Signature: ____________________________________________________________

Insurance card ID Number (not your SS#): ________________________________

Flu Shot Registration Form (South Carolina)