IMMUNIZATION ENCOUNTER FORM Health Insurance? NO TYPE: ____________ ID #_________________ GROUP #__________ Utah Medicaid? NO TYPE: ___________ ID # _________________ MONTH ___________
Patient Name: (First, Middle Initial, Last) ________________________________________________________________ Date of Birth: _____/_____/_____ Age: ______ Gender:
Female Phone #: __________________________
Address: _____________________________#: ________ City: ___________________ State: __________ ZIP: _______ Race: Screening Questions for Today's Immunizations Please answer these question concerning the individual receiving immunizations today by checking the boxes below
Do you have any chronic diseases? Child < 5 years of age with recurrent wheezing?
Have allergies to medications, food, latex or any vaccine?
Had a serious reaction to a vaccine in the past?
Ever had a seizure, brain, Guillain-Barre syndrome, or other nervous system problem?
Has or lives with someone that has cancer, leukemia, AIDS, or any other immune system problem?
Taken cortisone, prednisone, other steroids, or anti-cancer drugs, immunosuppressive medication, or had
radiation treatments in the past 3 months? Child or adolescent taking aspirin? Received transfusion of blood or blood products, or been given an immune (gamma) globulin in the past year?
Pregnant or at risk of becoming pregnant within the next month?
Received any vaccinations in the past four weeks?
I have been given a copy and have read or had explained to me, the information contained in the Vaccine Information Statement(s) about the disease(s) and vaccine(s). Any questions I had were answered to my satisfaction. I understand the benefits and risk of the vaccine(s) and request that the vaccine(s) indicated be given to me or the person for whom I am authorized to make this request. I certify that I have received a copy or been given the opportunity to read the Notice of Privacy Practices. I agree that the information on this form may be shared with schools, day care centers, health care providers, and others to verify immunization status, for public health studies, or when medically necessary. I hereby release the Utah County Government and their employees from all claims arising from such immunizations. I understand that if I have insurance that covers vaccines, I am not eligible for the Vaccine for Children program. I hereby authorize the Utah County Health Department to submit claims to my Medicaid, Medicare, and/or UCHD contracted insurances. I understand that my health insurance coverage could have certain restrictions and limitations. I agree to pay the full amount for any and all related charges, if they are not covered by my insurance for any reason. If I fail to pay for these services and charges within 90 days of receiving notice that the charges are not covered for any reason, my account will be turned over to a collection agency. I hereby expressly agree to pay all costs of collection fees including an additional collection of 35%. I further agree to pay all court costs and attorney’s fees should legal action become necessary. Due to the higher cost to provide insurance billing services, I understand that the amount billed to my insurance company is higher than the discounted amount I would have paid if I had chosen to pay at the time of service. I understand that I will be charged the full cost of the vaccines if I do not pay today and my insurance company does not cover the costs for any reason. I hereby request and authorize the Utah County Health Department to submit claims to my Medicaid, Medicare, and/or UCHD contracted insurances. JURISDICTION AND VENUE The terms and conditions contained within this agreement shall be governed by the laws of the State of Utah and shall be construed and interpreted in accordance with those laws. Any action or proceeding brought by either party which is based upon or derived from, or in any way related to this agreement shall be brought in a court of competent jurisdiction within the state of Utah. The parties hereto consent to their personal jurisdiction of said court. Authorization Signature: _____________________________ Date: ____/____/_____Relation, if other than self_______________
Please Print Name: ________________________________________________
Date printed on Vaccine Information Sheet: MULTIPLE VACCINES 11/16/12; DTAP/DT 05/17/07; HEP A 10/25/11; HEP B 2/02/12; HIB12/16/98; HPV 2/22/12; IG 5/1/94; INFLUENZA 07/02/12; MENINGO 10/14/11; MMR 4/20/12; MMRV 05/21/10; PNEU23 10/06/09; PNEU 13 4/16/10; POLIO 11/08/11; PPD 4/25/05; RABIES 10/06/09; ROTAVIRUS 12/06/10; SHINGLES 10/06/09; TD 1/24/12; TDAP 1/24/12; TYPHOID 5/29/12; VARICELLA 3/13/08; YELLOW FEVER 03/30/11
CODE VACCINE CATEGORY PAYMENT INFORMATION Cash/Check/Visa or MasterCard/Contract INSURANCE: 291 Total Costs for Today’s Vaccines/Insurance Provider: Total Amount Paid: Nurse One ID # Nurse Two ID# Operator ID#:
General Information - Influenza Vaccination The Disease: Influenza (flu) is caused by viruses. The fever, chills, headache, dry cough and muscle aches of flu may last from several days to more than a week, but complete recovery is usual. Certain groups of people, however, are much more likely to suffer major complications if they get the flu. People over age 65, residents of nursing hom