Microsoft word - hdf 129 iz record eng and spanish 10.3.12.doc
NEVADA COUNTY PUBLIC HEALTH DEPARTMENT - Immunization Record
TRUCKEE MSV: GV NSJ WA Mother’s First Name Public Health Use Only
Any serious reactions to other Immunizations?
Have you ever had a serious reaction to eggs,
neomycin, streptomycin, thimerosol or gelatin?
Have you had a convulsion, seizure, or problem with
Do you or anyone in your household have cancer,
leukemia or other disease causing immune system
Are you taking cortisone, prednisone, other steroids
Have you had a gamma globulin shot or blood
Have you had any shots in the past 2 weeks? What
Vaccine Not Given, client ineligible Signature 317 / VFC Eligibility
The following statements will help us determine if you or your child may receive immunizations through the 317/Vaccine For Children (VFC) program. Incomplete forms will not be accepted and, therefore, could prevent your child from being vaccinated through this program.
Please check only 1 box below:
1. You or your child is Child Health and Disability Prevention (CHDP) Program or Medi-Cal eligible.
2. You or your child does not have private health insurance.
3. You or your child is an American Indian or Alaskan Native.
4. You or your child’s health insurance does not cover vaccines.
Medicare Non Participation Policy Agreement
Nevada County Public Health does not bill Medicare for any services.
“With respect to the opt-out provisions, the Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 40.5 states that when a physician/practitioner opts out of Medicare, Medicare covers no services provided by that individual and no Medicare payment can be made to that physician or practitioner directly or on a capitated basis. Additionally, no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program”.
By signing below I understand that Nevada County Public Health does not bill Medicare for the services I am receiving today.
I understand that the services I am paying cash for today cannot be reimbursed from Medicare so I will not submit a claim.
Please read and sign the following: I have been given a copy and have read, or have had explained to me the information contained in the Vaccine Information Statement(s) about the disease(s) and the vaccine(s) indicated. I have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine(s) and request that the vaccine(s) indicated be given to me or to the person named above for whom I am authorized to make this request. I understand that Nevada County Public Health Department enters immunization information into the California Immunization Registry (CAIR). I hereby authorize the Nevada County Public Health Department, to release this information to my designated medical provider(s) and school(s). Print Name (Parent/Guardian/Self) Signature (Parent/Guardian/Self)
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