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Central Coast VIA & Hospice 20122013 Influenza IMMUNIZATION PREPAYMENT/CONSENT FORM PLEASE PRINT Student Name: (Last) (First) Date of Birth: School Name: Parents (or Guardians) Name: Telephone Number:
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Start by carefully reading through the form and familiarizing yourself with its sections and instructions.
02
Ensure that you have all the necessary information and documentation required to complete the form, such as your personal details, insurance information, and healthcare provider's contact information.
03
Begin by providing your full name, date of birth, and contact information in the designated sections.
04
Fill in your healthcare provider's name, address, and contact details accurately.
05
If applicable, indicate your insurance information, including the insurance company's name, policy number, and group number.
06
In the section related to flu prepayment, specify the amount you are willing to pay in advance for the flu vaccination.
07
Sign and date the form at the bottom to certify that the information provided is accurate and complete.
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Keep a copy of the filled-out form for your records.
09
Submit the form to your healthcare provider, either in person or by following their specific submission instructions.

Who needs 2012-13 flu prepayment-consent formdoc:

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Individuals who wish to receive the flu vaccination during the 2012-13 flu season may need to fill out this form.
02
It may be required by healthcare providers or healthcare facilities to ensure proper documentation and consent for administering the flu vaccine.
03
Some insurance companies or healthcare plans may also request this form as part of their payment or reimbursement process for flu vaccinations.
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13 flu prepayment-consent formdoc is a document used to prepay for flu vaccines.
Healthcare providers, clinics, and organizations purchasing flu vaccines in advance are required to file 13 flu prepayment-consent formdoc.
To fill out the form, provide information about the number of flu vaccines needed, payment details, and consent for prepayment.
The purpose of 13 flu prepayment-consent formdoc is to secure flu vaccine doses in advance and streamline the payment process.
Information such as the quantity of flu vaccines required, payment method, and consent for prepayment must be reported on 13 flu prepayment-consent formdoc.
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2012 VNA ccvna thimerosal ext PREPAYMENT undersigned soreness redness IMMUNIZATION Influenza outlines Hospice Vaccination seasonal Guardians latex enclosed Coordinator Administer vaccine

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