INGHAM COUNTY HEALTH DEPARTMENT - INFLUENZA CLINIC Clinic Site: ______

Registration Form – Patient Information

PLEASE PRINT CLEARLY
Fill out all “shaded” areascompletely on FRONT AND BACK

Last / Family Name ______

First Name______

Address______

City, State, ZIP ______

Social Security # ______

County of Residence: Ingham Other ______

Date of Birth: ______/______/______Age ______

month day year(months if under

Marital Status: 3 years old)

 Married  Separated  Divorced  Widowed  Never Married

Daytime Phone # ______

Cell/Alternate Phone #: ______

*Head of Household name and date of birth:

______

Please answer the following questions:

Patient is:  Male  Female

Patient is:  Arabic  Hispanic Neither

Patient speaks:  Arabic English  Spanish

 Other (specify)______

Patient is(select all that apply):

 American Indian  Asian  Black/African American

NativeHawaiian Pacific Islander  White

Patient Homeless Status:

 N = not homeless  H = homeless shelter

 T = transitional  D = doubling up O = other

 S = street U = unknownhomeless living arrangement

Veteran Status (an individual who completed service in the Uniformed Services of the United States):

YesNo

Total # of Family Members (Dependents) Living in Home:______

Household Income (check only 1):  Weekly $______ Monthly $______ Yearly $______

Income Source (Social Security, Disability, Employer, Unemployment, DHS/Cash Grant, etc)__________

INSURANCE INFORMATION: Does your insurance cover immunizations? ___Yes ___No

If “NO” would you like to apply for the ICHD Discount Program? ____Yes ____No

A copy of your insurance card(s) is required.

Important Notice: We can only bill Medicare B and listed commercial insurances if PRIMARY. We cannot bill Medicare managed care plans (i.e., BCN, AARP, Humana, etc.) unless they are private fee for service (PFFS). You may refer back to your primary care physician or pay full price here. You are responsible for full payment if insurance rejects claim.

Primary Insurance

Name of Insurance: Group #

Subscriber ID / Contract Number Policyholder’s Relationship to Patient

Policyholder’s Name Policyholder’s Date of Birth

Secondary Insurance

Name of Insurance: Group #

Subscriber ID / Contract Number Policyholder’s Relationship to Patient

Policyholder’s Name Policyholder’s Date of Birth

Other Insurance

Name of Insurance: Group #

Subscriber ID / Contract Number Policyholder’s Relationship to Patient

Policyholder’s Name Policyholder’s Date of Birth

INGHAM COUNTY HEALTH DEPARTMENT – INFLUENZA CLINIC

Patient Name:

(Last/Family) (First) (Middle Initial)

Date of Birth: ______/______/______Age: ______(months if under 3 years old)

month day year

PLEASE CHECK THE APPROPRIATE BOX FOR EACH QUESTION:

1.Have you had a fever within the past 2 days?...... □Yes□No

2.Have you had a flu shot before?...... □Yes□No

3.Have you ever had a serious reaction to a flu shot or any previous immunization?...□Yes□No

4.Do you have any allergies? If so, list______..□Yes□No

5.Do you have a history of Guillain Barrẻ Syndrome?...... □Yes□No

6.Have you had a pneumonia shot in the past? If yes, year______...... □Yes□No

For Flu Mist ONLY (Nasal Spray Vaccine):

1.Are you between 2 years through 49 years of age? (Not yet 50) If no, STOP HERE!□Yes□No

2.Do you have any diagnosed medical condition? If yes, what______□Yes□No

3.Do you take prescribed medications on a regular basis?...... □Yes□No

4.Are you pregnant or breast feeding?...... □Yes□No

5.Do you have a history of asthma?...... □Yes□No

6.Do you have close contact to a severely immune compromised person?...... □Yes□No

PLEASE READ AND SIGN THE STATEMENT BELOW:

Receipt of Privacy Notice

I acknowledge I have been offered an Ingham County Health Department Notice of Health Information and Privacy Practices. □IAccept □IDecline

Authorization for Vaccine Administration and billing:

I have read or have had explained to me the information in the Vaccine Information Statement. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risk of the specified vaccine(s). I ask that the vaccine(s) be given to me or to the person named for whom I am authorized to make this request.

I authorize the release of any information necessary to process insurance claims for immunization services. I request that any money due me for medical benefits be assigned to ICHD. I release that I am responsible for any deductibles, copays and non-covered benefits. If I have insurance that does not have a contract with ICHD, I understand that I am responsible for payment of services today.

The authorization for release of information is effective for one (1) year from date of service.

PRINT HERE:Patient/Parent/Guardian Name (if patient is under 18 years old):

SIGN HERE:Patient/Parent/Guardian (if patient is under 18 years old):

Date______

Date Vaccine &
VIS Given / Given1 / Vaccine / Code / Diag / Vaccine
Manufacturer / Vaccine
Lot # / Site2 / Vaccine
Administrator / VIS
Date
□ V / Flu <36 mo syr / 90655 / V04.81 / 2011-12
□ V / Flu >36 mo sdv / 90656 / V04.81 / 2011-12
□ V / Flu >36 mo mdv / 90658
(Q2038 Medicare only) / V04.81 / 2011-12
□ V / Influenza flu mist / 90660 / V04.81 / 2011-12
□ V / PPSV23 / 90732MD / V03.82 / 10-06-09
□ V / PPSV23 / 90732SD / V03.82 / 10-06-09

1Given: V = VFC

2SiteKey: LA = Left Arm; RA = Right Arm; LL = Left Leg; RL = Right Leg; N = Nasal