PA Influenza Vaccine Administration Record & Consent - Chester County 2014-2025 free printable template

INFLUENZA VACCINE ADMINISTRATION RECORD & CONSENT Adults 19 and older Information about person to receive vaccine PLEASE PRINT: Last Name First Name DATE OF BIRTH Address Apt/Suite City / / State

How to fill out influenza vaccine administration record

How to fill out PA Influenza Vaccine Administration Record & Consent

1. Obtain the PA Influenza Vaccine Administration Record & Consent form.
2. Fill in the patient's personal information, including name, date of birth, and contact details.
3. Document any relevant medical history that may affect vaccination, including allergies and current medications.
4. Indicate the date of the vaccination and the specific influenza vaccine being administered.
5. Provide a consent signature from the patient or guardian, confirming understanding of the vaccine and its risks.
6. Complete any additional sections as required, such as the name of the administering healthcare professional.

Who needs PA Influenza Vaccine Administration Record & Consent?

1. All individuals receiving the influenza vaccine, including children and adults.
2. Parents or guardians of minors seeking influenza vaccination for their children.
3. Healthcare providers administering the vaccine who need to document the consent process.

People Also Ask about

What is CPT code 90674?

CPT® 90674, Under Vaccines, Toxoids. The Current Procedural Terminology (CPT®) code 90674 as maintained by American Medical Association, is a medical procedural code under the range - Vaccines, Toxoids.

What is the administration code for 90686?

90686=Inactivated quadrivalent influenza vaccine (IIV4), split virus, preservative free, 0.5-mL dosage, for intramuscular use.

What is CPT code 90471 billing guidelines?

For vaccines given the same day as a G-Code vaccine, use 90471. For example, if a patient receives a flu shot and tetanus shot, you would bill G0008 for the flu vaccine and 90471 for the tetanus vaccine; also add modifier 59 (distinct procedural service) to the G code.

What is CPT code 90471 administration?

90471 Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injection(s); one vaccine (single or combination vaccine/toxoid. Service limit 1 per day.

Is CPT 90471 age specific?

Code 90471 is used when the drug is administrated by a medical assistant or nurse and the patient does not see the physician at all. This code would also be used for any patient 19 years of age or older regardless if physician is present and does face-to-face counseling.

What is the CPT code for flu vaccination administration?

90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered.

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What is PA Influenza Vaccine Administration Record & Consent?

The PA Influenza Vaccine Administration Record & Consent is a document used to record the administration of the influenza vaccine in Pennsylvania, which includes consent from the patient or guardian for the vaccine to be given.

Who is required to file PA Influenza Vaccine Administration Record & Consent?

Healthcare providers administering the influenza vaccine in Pennsylvania are required to file the PA Influenza Vaccine Administration Record & Consent for each patient receiving the vaccine.

How to fill out PA Influenza Vaccine Administration Record & Consent?

To fill out the PA Influenza Vaccine Administration Record & Consent, healthcare providers should enter the patient's information, vaccine details, and the date of administration, along with obtaining the appropriate consent signatures.

What is the purpose of PA Influenza Vaccine Administration Record & Consent?

The purpose of the PA Influenza Vaccine Administration Record & Consent is to ensure proper documentation of vaccine administration, ensure informed consent, and facilitate tracking of immunization records in Pennsylvania.

What information must be reported on PA Influenza Vaccine Administration Record & Consent?

The information that must be reported includes the patient's name and demographic details, vaccine type, lot number, administration date, healthcare provider's information, and signatures for consent.