Department of Health Name and Address

Date:______

PATIENT INFORMATION:

Patient Name: ______

Street Address: ______City: ______State: ______Zip:______

Phone - Home: ______Cell: ______Work: ______E-mail:______

Date of Birth: _____/_____/______Age: ______Patient Sex: ⎕Male ⎕Female

Parent/Guardian Name: ______Mother’s Maiden Name: ______

Physician/Family Doctor: ______

Does the patient have, or is the patient covered by health insurance? ⎕Yes⎕No

INSURANCE INFORMATION:⎕Medicaid⎕Medicare⎕Private Insurance Insurance does not cover

Insurance Company Name:______Policy Holder (Insured’s Name): ______

Policy Holder’sDate of Birth _____/_____/______Policy Number: ______Group Number: ______

Insured’s relationship to the patient:⎕Spouse⎕Child⎕SelfSocial Security Number: ______

  1. Are you allergic to any foods or medicine? (eggs, gelatin, yeast, Penicillin or latex)⎕ Yes⎕No
  2. Have you ever had an allergic reaction or other problem after a vaccination?⎕ Yes⎕No
  3. Have you ever had a SEIZURE or Guillain-Barre Syndrome?⎕Yes⎕No
  4. Are you sick today? ??⎕Yes⎕No
  5. Do you have a long-term health problem, such as heart disease, lung disease (e.g. asthma)

kidney disease, metabolic disease (e.g. diabetes) or a blood disorder?⎕ Yes⎕No

  1. Do you have a weakened immune system because of HIV/AIDS or other disorder,

long-term treatment such as steroids or cancer treatment with x-rays or drugs?⎕ Yes⎕No

  1. Do you live with or have close contact with anyone with severely weakened immune

requiring care in a protected environment?⎕ Yes⎕No

  1. Do you take aspirin or other salicylate medication?⎕Yes⎕No
  2. Have you received anyvaccine in the past 4 weeks?⎕Yes⎕No
  3. Are you pregnant or could become pregnant within the next month?⎕Yes⎕No

CONSENT TO TREAT: I authorize the (County Name Here)County Department of Healthto administer treatment as deemed necessary for care of the patient named above. I certify that I am the patient, parent or legal guardian of the patient. I also certify that no guarantee or assurance has been made as to the results that may be obtained from the treatment.

RELEASE OF INFORMATION: I authorize this information to be released to the insurance carrier.

ASSIGNMENT OF BENEFITS: All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. The patient/parent/responsible party is responsible for any unpaid balances. Co-Payments will be made at the time of service. I request that payment of authorized Medicare, Medicaid, or other insurance company benefits be made to (County Name Here)County Department of Healthfor any services furnished to me by the (County Name Here)County Department of Health. Regulations pertaining to Medicare and Medicaid assignment of benefits apply.

My signature indicates agreement to the above and that all information provided above is true and accurate:

______

Signature of Patient or Legal Representative Date

If patient is under the age of 18, please print full name of parent or legal representative:

______

Staff use only:

Review by: ______RN______

Signature Date

IMMUNIZATION ADMINISTRATION
PROCEDURE CODE / FEE
Immunization administration, 1 vaccine (single or combination vaccine/toxoid) / ⎕ / 90471 / 15
each additional vaccine (single or combination vaccine/toxoid) / ⎕ / 90472 / 15
Immunization administration by intranasal or oral route, 1 vaccine (single or combination vaccine/toxoid) / ⎕ / 90473 / 15
each additional intranasal or oral vaccine administration (single or
combination vaccine/toxoid) / ⎕ / 90474 / 15
Administration of Influenza vaccination (MEDICARE ONLY) / ⎕ / G0008 / 15
Administration of Pneumococcal vaccination (MEDICARE ONLY) / ⎕ / G0009 / 15
Administration of Hepatitis B vaccination (MEDICARE ONLY) / ⎕ / G0010 / 15
IMMUNIZATIONS
VACCINE PRODUCT / VACCINE COMPONENTS / CPT / ICD-9 / FEE
ActHIB / Hib / ⎕ / 90648 / V03.81 / 35
Adacel / Tdap (tetanus – 1diphtheria – acellular pertussis) / ⎕ / 90715 / V06.1 / 45
Boostrix / Tdap / ⎕ / 90715 / V06.1 / 45
Cervarix / HPV / ⎕ / 90650 / V04.89 / 162
Comvax / HepB – Hib / ⎕ / 90748 / V06.8 / 0
Daptacel / DtaP / ⎕ / 90700 / V06.1 / 40
Decavac / Td (tetanus – diphtheria toxoids absorbed_ / ⎕ / 90714 / V06.5 / 0
Engerix – B ADULT / HepB / ⎕ / 90746 / V05.3 / 45
Quadrivalent 3 yrs + / Influenza / 90686 / V04.81 / 20
Engerix – B ped / HepB / ⎕ / 90745 / V05.3 / 20
Fluarix / Influenza / ⎕ / 90656 / V04.81 / 20
FluMist / Influenza / ⎕ / 90660 / V04.81 / 20
Fluvirin / Influenza / ⎕ / 90658 / V04.81 / 20
Fluvirin, age 6-35 months / Influenza / ⎕ / 90657 / V04.81 / 20
Fluvirin, PF / Influenza / ⎕ / 90656 / V04.81 / 20
Fluzone, age 6-35 months / Influenza / ⎕ / 90657 / V04.81 / 20
Fluzone, age 3+ / Influenza / ⎕ / 90658 / V04.81 / 20
Fluzone No Preservative Pediatric, age 6-35 mths / Influenza / ⎕ / 90655 / V04.81 / 20
Fluzone No Preservative, age 3+ / Influenza / ⎕ / 90656 / V04.81 / 20
Gardasil / HPV / ⎕ / 90649 / V04.89 / 162
Havrix, 2 dose / Hep A / ⎕ / 90633 / V05.3 / 23
Havrix, 3 dose / Hep A / ⎕ / 90634 / V05.3 / 0
Infanrix / DtaP / ⎕ / 90700 / V06.1 / 40
Influenza, pandemic, intranasal / Influenza / ⎕ / 90664 / V04.81 / 25
Influenza, pandemic PF / Influenza / ⎕ / 90666 / V04.81 / 25
Influenza, pandemic, adjuvanted / Influenza / ⎕ / 90667 / V04.81 / 25
Influenza, pandemic IM / Influenza / ⎕ / 90668 / V04.81 / 25
IPOL / IPV / ⎕ / 90713 / V04.0 / 40
Kinrix / DtaP – IPV / ⎕ / 90696 / V06.8 / 56
MMR II / Measles, mumps, rubella / ⎕ / 90707 / V06.4 / 75
Menactra / Meningococcal / ⎕ / 90734 / V03.89 / 125
MenHybrix / Meningococcal, HiB / ⎕ / 90644 / V06.8 / 0
Menomune / Meningococcal / ⎕ / 90733 / V03.89 / 137
Menveo / Meningococcal / ⎕ / 90734 / V03.89 / 99
Pediarix / Dtap – HepB – IPV / ⎕ / 90723 / V06.8 / 77
PedvaxHIB / Hib / ⎕ / 90647 / V03.81 / 0
Pentacel / Dtap – Hib – IPV / ⎕ / 90698 / V06.8 / 65
Pneumo-vax 23 / Pneumoccal / ⎕ / 90732 / V03.82 / 0
Prevnar-13 / Pneumoccal / ⎕ / 90670 / V03.82 / 165
ProQuad / MMR-V / ⎕ / 90710 / V06.8 / 170
Recombivax HB ped/adult / HepB / ⎕ / 90744 / V05.3 / 0
Rotateq, 3 dose / Rotavirus / ⎕ / 90680 / V04.89 / 0
Rotarix, 2 dose / Rotavirus / ⎕ / 90681 / V04.89 / 122
Td – adult, 7+ years / Tetanus and diphtheria toxois absorbed / ⎕ / 90718 / V06.5 / 0
TriHIBit / DTAP – Hib / ⎕ / 90721 / V06.8 / 0
Tripedia / Dtap / ⎕ / 90700 / V06.1 / 0
Twinrix / HepA – HepB / ⎕ / 90636 / V06.8 / 70
VAQTA / HepA / ⎕ / 90632 / V05.3 / 38
Varivax / Varicella / ⎕ / 90716 / V05.4 / 108
Zostavax / Zoster/Shingles / ⎕ / 90736 / V04.89 / 187

To Be Completed by Person Administering Vaccine

Vaccine / Manufacturer/Lot Number/
Expiration Date / Signature of Vaccinator / Site / Route / Date of VIS
MCV4 / Left or Right Deltoid / IM / 05/14/2011
Tdap / Left or Right Deltoid / IM / 05/09/2013
Varicella / Left or Right Arm / SC / 03/13/2008
MMR / Left or Right Arm / SC / 04/20/2012
IPV / Left or Right Arm / SC
IM
(Please circle) / 11/08/2011
Hep B / Left or Right Arm / IM / 02/02/2012
Hep A / Left or Right Arm / IM / 10/25/2011
DTaP / Left or Right Arm / IM / 05/17/2007
HPV4 / Left or Right Arm / IM / 05/03/2011
HPV2 / Left or Right Arm / IM / 05/03/2011
IIV / Left or Right Deltoid / IM / 7/26/2013
LAIV / Left or Right Deltoid / IM / 7/26/2013

The HPV vaccine is not a school requirement; however, it is a requirement of school-based clinics enrolled in the VFC program to offer to offer the HPV vaccine to both boys and girls.

Entered into CHIRP by ______Date ______