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Blue Cross Aetna Gateway Basinger HumanaPleasant Hills Apothecary 25 Gill Hall Road Jefferson Hills PA 15025 pH: 4126537566 Fax: 4126530755Medicare UPMC United HC PA H&WCOVID19 Immunization Consent
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How to fill out pha covid intake form

01
Obtain PHA COVID intake form from the designated website or medical facility.
02
Fill out personal information such as name, date of birth, address, and contact information.
03
Answer questions regarding COVID symptoms, recent travel history, and exposure to confirmed cases.
04
Provide information on pre-existing medical conditions or medications being taken.
05
Sign and date the form acknowledging the accuracy of the provided information.

Who needs pha covid intake form?

01
Individuals who are seeking medical evaluation or testing for COVID-19
02
Individuals who have been in close contact with someone who tested positive for COVID-19
03
Individuals who are exhibiting symptoms of COVID-19
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The PHA COVID Intake Form is a document used by Public Housing Authorities to collect relevant information regarding COVID-19 vaccinations or infections from applicants and residents.
Applicants for housing assistance and current residents who are required to report their COVID-19 status or vaccination information must file the PHA COVID Intake Form.
To fill out the PHA COVID Intake Form, individuals should provide their personal information, including their name, address, date of birth, COVID-19 vaccination status, and any relevant medical history as requested on the form.
The purpose of the PHA COVID Intake Form is to gather information to ensure the health and safety of residents, to manage housing resources effectively, and to comply with public health guidelines.
Individuals must report personal details such as their name, contact information, COVID-19 vaccination status, any recent infections, and any other information as required by the form.
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