Microsoft word - englishencounterform1page

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#:

Source: http://page.co.utah.ut.us/Dept2/Health/Nursing/Documents/EncounterFormEnglish.pdf