ࡱ> _ bjbjjj k,b,b / hhh$PlHD0F]]]///////$J25/h]]]]/7/G&G&G&]8h/G&]/G&G&:[+,P+K i*+ o//00+.55++5h+]]G&]]]]]//"X]]]0]]]]5]]]]]]]]] B : The completion of this form is necessary for every vaccine recipient. If no insurance information is available, please fill out as much as possible using existing information. Information about the person to receive vaccine (please print): *Required Fields Name: (Last, First, MI)*Date of birth: * _____ ____ _____ Month Day YearAge*Sex: (Circle)* Male FemaleStreet Address:* City:*State: *Zip:* Phone:* ( ) Insurance Information: Include the whole member ID number and any letters that are part of that number Name of Insurance Company:* Member ID Number:*Group ID Number: (if available)Medicare Number:Is Medicare Primary? Yes NoIs Subscriber Retired? Yes No  If person getting vaccinated is not the insurance subscriber/policy holder, please complete the following: Subscribers Name: (Last, First, MI)*Subscribers Date of Birth: * _____ ____ _____ Month Day YearSex: (Circle)* Male FemaleSubscribers Street Address:* (If different from address above) City:*State:*Zip: * Phone:* ( )Patient Relationship to Subscriber: (Circle)* Spouse Child Other I give permission for my insurance company to be billed. X ______ Date: ________________ (Signature of patient, parent or legal guardian) ***************************************************************************************************************************Place Photo Copy of All Insurance Cards Here: For children 18 years of age and younger:      For Clinic/Office Use Only: Date of ServiceVax TypeVaccine MfgrState Supplied (Circle)Preserv Free*Lot NoExp DateDose (mL) Injection Route (Circle)Injection Site (Circle)Date On VISDate VIS GivenIIV4Yes NoYes No0.25 0.5IMR Arm L Arm R Leg L LegLAIV4AstraZenecaYes NoYes0.2IntranasalN/AFlucelvax (ccIIV4)SeqirusYesYes0.5IMR Arm L ArmIIV3NoYes No0.5IMR Arm L Arm R Leg L LegFluzone High Dose (IIV3-HD)Sanofi PasteurNoYes0.5IMR Arm L ArmFluad (aIIV3)SeqirusNoYes0.5IMR Arm L ArmFlublok (RIV4)Sanofi PasteurNoYes0.5IMR Arm L Arm PCV13PfizerNoYes0.5IMR Arm L ArmPPSV23MerckYes No Yes0.5IM SCR Arm L Arm Signature of Vaccine Administrator: _________________________________________ Vaccine Types & Definitions: TermDefinitionIIV4Inactivated influenza vaccine, quadrivalentLAIV4Live influenza vaccine, quadrivalent, for intranasal useccIIV4Cell culture-based inactivated influenza vaccine, quadrivalentIIV3Inactivated influenza vaccine, trivalentIIV3-HDInactivated influenza vaccine, trivalent, high doseaIIV3Adjuvanted inactivated influenza vaccine, trivalentRIV4Recombinant influenza vaccine, quadrivalentPCV13Pneumococcal conjugate vaccine, 13-valentPPSV23Pneumococcal polysaccharide vaccine, 23-valent Please Note: For billing purposes preservative free vaccines are vaccines in pre-filled syringes or single dose vials. 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