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NPI:1245236306INFLUENZA VACCINE 20182019 HEALTH SCREEN & PERMISSION FORM Full Name:Date of Birth: / / Town/City:Street Address: Grade:School Name: Age:Gender: Flip Code:Teacher:Daytime Phone:School
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What is is this person insured?
This person is insured if they have a valid insurance policy.
Who is required to file is this person insured?
The person or entity responsible for the insurance policy is required to file if this person is insured.
How to fill out is this person insured?
To fill out if this person is insured, provide the necessary information related to the insurance policy.
What is the purpose of is this person insured?
The purpose is to verify if this person has insurance coverage.
What information must be reported on is this person insured?
Information such as policy number, coverage amount, and insurance provider must be reported.
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